Provider Demographics
NPI:1619390846
Name:JAGTAP, PRASHANT (MD)
Entity Type:Individual
Prefix:
First Name:PRASHANT
Middle Name:
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 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-1000
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6417
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1000
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-757-6417
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139333207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine