Provider Demographics
NPI:1083802763
Name:LAL, JAGDISH (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGDISH
Middle Name:
Last Name:LAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAGDISH
Other - Middle Name:
Other - Last Name:LAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6977 NEXUS CT
Mailing Address - Street 2:STE. # 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-2650
Mailing Address - Country:US
Mailing Address - Phone:910-864-7933
Mailing Address - Fax:910-272-7177
Practice Address - Street 1:6977 NEXUS CT
Practice Address - Street 2:STE. # 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2650
Practice Address - Country:US
Practice Address - Phone:910-864-7933
Practice Address - Fax:910-272-7177
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09900578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912136Medicaid
NC8912136Medicaid
2326252Medicare PIN
G26846Medicare UPIN
G26816Medicare UPIN
2274618AMedicare PIN