Provider Demographics
NPI:1073954962
Name:JAGGI, KANIKA (MD)
Entity Type:Individual
Prefix:
First Name:KANIKA
Middle Name:
Last Name:JAGGI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 S ANTHONY BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-3386
Mailing Address - Country:US
Mailing Address - Phone:260-425-2690
Mailing Address - Fax:260-425-2691
Practice Address - Street 1:5717 S ANTHONY BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-3386
Practice Address - Country:US
Practice Address - Phone:260-425-2690
Practice Address - Fax:260-425-2691
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103736207Q00000X, 390200000X
IN01076756A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201359770Medicaid
IN150640058Medicare UPIN