Provider Demographics
NPI:1093706335
Name:JAGODA, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:JAGODA
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:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1817
Mailing Address - Country:US
Mailing Address - Phone:480-237-9377
Mailing Address - Fax:480-237-9377
Practice Address - Street 1:2009 E 5TH ST STE 9
Practice Address - Street 2:STE 9
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-3067
Practice Address - Country:US
Practice Address - Phone:480-237-9377
Practice Address - Fax:480-237-9377
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25979207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1073806337Medicare NSC
AZZ146931Medicare PIN
AZG68133Medicare UPIN
AZAZ13967Medicare Oscar/Certification