1053338947 NPI number — JAGDISH LAL MD PA

Table of content: (NPI 1053338947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053338947 NPI number — JAGDISH LAL MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAGDISH LAL MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053338947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-864-7933
Provider Business Mailing Address Fax Number:
910-864-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6977 NEXUS COURT
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-2651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-864-7933
Provider Business Practice Location Address Fax Number:
910-864-3180
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAL
Authorized Official First Name:
JAGDISH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
910-864-7933

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  9900578 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0438753 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12136 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 084806830 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8912136 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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