Provider Demographics
NPI:1073694006
Name:JABEZ, JEGAN (MD)
Entity Type:Individual
Prefix:
First Name:JEGAN
Middle Name:
Last Name:JABEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8734 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1617
Mailing Address - Country:US
Mailing Address - Phone:269-473-2797
Mailing Address - Fax:269-925-8847
Practice Address - Street 1:1686 COLFAX AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-7355
Practice Address - Country:US
Practice Address - Phone:269-925-8842
Practice Address - Fax:269-925-8847
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301064652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1101111252OtherBC/BS
MI4301064652OtherMEDICAL LICENSE NUMBER
MI415194310Medicaid
MIF53539Medicare UPIN
MI415194310Medicaid