Provider Demographics
NPI:1629190095
Name:JAGTAP, DEEPA BAI (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:BAI
Last Name:JAGTAP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3577 W 13 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6710
Mailing Address - Country:US
Mailing Address - Phone:248-288-4500
Mailing Address - Fax:248-288-0450
Practice Address - Street 1:3577 W 13 MILE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-288-4500
Practice Address - Fax:248-288-0450
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087460207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H273300OtherBLUE SHIELD
MI1629190095Medicaid
MIMI4989424Medicare PIN