Basic Information
| Provider Information | |||||||||
| NPI: | 1639597529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | SUPRIYA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805385006 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 LADY MOON DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805284426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708103894 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2014 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 036-150328 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.