Provider Demographics
NPI:1619973823
Name:JAGJIVAN, BIPINCHANDRA
Entity Type:Individual
Prefix:
First Name:BIPINCHANDRA
Middle Name:
Last Name:JAGJIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 MAIN ST SOUTH
Mailing Address - Street 2:UNION SQUARE BLDG #1 NVRA IMAGING NETWORK
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488
Mailing Address - Country:US
Mailing Address - Phone:203-264-7999
Mailing Address - Fax:203-264-7477
Practice Address - Street 1:385 MAIN ST SOUTH
Practice Address - Street 2:UNION SQUARE BLDG #1 NVRA IMAGING NETWORK
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488
Practice Address - Country:US
Practice Address - Phone:203-264-7999
Practice Address - Fax:203-264-7477
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0297202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001297200Medicaid
CT300003755Medicare ID - Type Unspecified
CT300003772Medicare ID - Type Unspecified
CT300003770Medicare ID - Type Unspecified
CTD400120755Medicare PIN
CT001297200Medicaid
CT300003758Medicare ID - Type Unspecified
CT300003773Medicare ID - Type Unspecified