1710972005 NPI number — DR. EDWARD J. JAGELA O.D., F.A.A.O.

Table of content: (NPI 1790729101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710972005 NPI number — DR. EDWARD J. JAGELA O.D., F.A.A.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAGELA
Provider First Name:
EDWARD
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D., F.A.A.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1710972005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/23/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 JOHNSON RD
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
STEUBENVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43952-2356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-283-3937
Provider Business Mailing Address Fax Number:
740-283-1858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 JOHNSON RD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
STEUBENVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43952-2356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-283-3937
Provider Business Practice Location Address Fax Number:
740-283-1858
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4201/T497 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000213650 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0149838001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1068565 . This is a "BUR OF WC (BRICKSTREET)" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0007520120 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0898953 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001720035 . This is a "MOUNTAIN STATE BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0898953 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4201T497 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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