Provider Demographics
NPI:1003886193
Name:KAGAN, JEFFREY MARK (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARK
Last Name:KAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 WILLARD AVE
Mailing Address - Street 2:SUITE 2-D
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2373
Mailing Address - Country:US
Mailing Address - Phone:860-665-1571
Mailing Address - Fax:860-667-3668
Practice Address - Street 1:365 WILLARD AVE
Practice Address - Street 2:SUITE 2-D
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2373
Practice Address - Country:US
Practice Address - Phone:860-665-1571
Practice Address - Fax:860-667-3668
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001309378Medicaid
CT110007914Medicare ID - Type Unspecified
CTE66144Medicare UPIN