Provider Demographics
NPI:1558578708
Name:JAGANNATHAN, JAYANT (MD)
Entity Type:Individual
Prefix:
First Name:JAYANT
Middle Name:
Last Name:JAGANNATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30775 STEPHENSON HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1618
Mailing Address - Country:US
Mailing Address - Phone:248-733-9904
Mailing Address - Fax:248-733-9906
Practice Address - Street 1:30775 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1618
Practice Address - Country:US
Practice Address - Phone:248-733-9904
Practice Address - Fax:248-733-9906
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301095038207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery