Provider Demographics
NPI:1326003955
Name:JAGADEESAN, JAGADA (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGADA
Middle Name:
Last Name:JAGADEESAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4884 HIGBEE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2578
Mailing Address - Country:US
Mailing Address - Phone:330-493-0072
Mailing Address - Fax:330-493-9101
Practice Address - Street 1:4884 HIGBEE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2578
Practice Address - Country:US
Practice Address - Phone:330-493-0072
Practice Address - Fax:330-493-9101
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-8668174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0532981Medicaid
OHJA054081Medicare ID - Type Unspecified
OH0532981Medicaid