Provider Demographics
NPI:1518175777
Name:JAGADEESHA, VINAY (MD)
Entity Type:Individual
Prefix:
First Name:VINAY
Middle Name:
Last Name:JAGADEESHA
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-391-2011
Mailing Address - Fax:843-391-2021
Practice Address - Street 1:701 CASHUA FERRY RD
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-8488
Practice Address - Country:US
Practice Address - Phone:843-391-2011
Practice Address - Fax:843-391-2021
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33118207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA56656978Medicare PIN
SCGP3161OtherMEDICAID GROUP
SCGP4840OtherMEDICAID GROUP
SCGP2826OtherMEDICAID GROUP
SCAA56656502Medicare PIN
SCAA56657153Medicare PIN
SC331180Medicaid