Provider Demographics
NPI:1659320281
Name:JAGTIANI, RAJA KISHINCHAND (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJA
Middle Name:KISHINCHAND
Last Name:JAGTIANI
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 1:297 S WASHINGTON AVE
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-3789
Mailing Address - Country:US
Mailing Address - Phone:201-387-0087
Mailing Address - Fax:201-387-2232
Practice Address - Street 1:297 S WASHINGTON AVE
Practice Address - Street 2:SUITE # 1
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-3789
Practice Address - Country:US
Practice Address - Phone:201-387-0087
Practice Address - Fax:201-387-2232
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA063561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7867000Medicaid
NJ7867000Medicaid
NJJA004017Medicare ID - Type Unspecified