Provider Demographics
NPI:1114381894
Name:JAGTAP, PRANAV M (MD)
Entity Type:Individual
Prefix:
First Name:PRANAV
Middle Name:M
Last Name:JAGTAP
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 578
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-0578
Mailing Address - Country:US
Mailing Address - Phone:947-207-1076
Mailing Address - Fax:
Practice Address - Street 1:36400 WOODWARD AVE STE 101
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0911
Practice Address - Country:US
Practice Address - Phone:947-207-1076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43015021562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry