Provider Demographics
NPI:1043257629
Name:JAGANNATH, THOPSIE V (MD)
Entity Type:Individual
Prefix:
First Name:THOPSIE
Middle Name:V
Last Name:JAGANNATH
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 1:4924 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-925-1050
Mailing Address - Fax:304-925-0581
Practice Address - Street 1:4924 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-925-1050
Practice Address - Fax:304-925-0581
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0072943000Medicaid
WV0072943000Medicaid
E60404Medicare UPIN