Provider Demographics
NPI:1639148372
Name:JAGGARD, PETER LOREN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:LOREN
Last Name:JAGGARD
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 1:3200 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1903
Mailing Address - Country:US
Mailing Address - Phone:847-492-4842
Mailing Address - Fax:847-492-4829
Practice Address - Street 1:3200 GRANT ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-492-4828
Practice Address - Fax:847-492-4810
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062564207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110213053OtherRAILROAD MEDICARE
ILK16293Medicare ID - Type Unspecified
210708Medicare ID - Type Unspecified
211076Medicare ID - Type Unspecified
C45601Medicare UPIN
K16292Medicare ID - Type Unspecified