Provider Demographics
NPI:1003578881
Name:JAGDEO, ALYSSA (OD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:JAGDEO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 RICHGROVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRAMPTON
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6P1X6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7800 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4057
Practice Address - Country:US
Practice Address - Phone:843-572-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-09
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2304152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist