Provider Demographics
NPI:1083667737
Name:JAGGERNAUTH, SIMEON (DO)
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:
Last Name:JAGGERNAUTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 S PINNACLE HILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8939
Mailing Address - Country:US
Mailing Address - Phone:479-271-8900
Mailing Address - Fax:479-715-8060
Practice Address - Street 1:602 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3364
Practice Address - Country:US
Practice Address - Phone:806-775-8200
Practice Address - Fax:305-488-1325
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3898207RX0202X
ARE9890207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH94210Medicare UPIN