Provider Demographics
NPI:1154327740
Name:AGRICOLA, JEFFREY D (DPM)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:AGRICOLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3731 GUION ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-7604
Mailing Address - Country:US
Mailing Address - Phone:317-931-0661
Mailing Address - Fax:317-927-0924
Practice Address - Street 1:277 E CARMEL DR
Practice Address - Street 2:STE D
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2609
Practice Address - Country:US
Practice Address - Phone:317-846-4111
Practice Address - Fax:317-846-1767
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN07000947A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200409540Medicaid
IN6332990001Medicare NSC
IN264350AMedicare PIN
INP00805636Medicare PIN
INU91344Medicare UPIN