Provider Demographics
NPI:1114014701
Name:MUDE, JAGDISH L (MD)
Entity Type:Individual
Prefix:
First Name:JAGDISH
Middle Name:L
Last Name:MUDE
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 1:30 E BROAD ST
Mailing Address - Street 2:11TH FL. ATTN: TONYA FASONE
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3414
Mailing Address - Country:US
Mailing Address - Phone:614-466-9930
Mailing Address - Fax:614-644-9116
Practice Address - Street 1:1756 SAGAMORE RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-1086
Practice Address - Country:US
Practice Address - Phone:330-467-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0775122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH12040Medicare UPIN
OHMU4035544Medicare ID - Type Unspecified