Provider Demographics
NPI:1659334332
Name:JAGIELLO, BENJAMIN P (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:P
Last Name:JAGIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1605 LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5858
Mailing Address - Country:US
Mailing Address - Phone:904-819-4478
Mailing Address - Fax:904-819-4993
Practice Address - Street 1:ONE LANDMARK NORTH 20399 ROUTE 19
Practice Address - Street 2:SUITE 203
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066
Practice Address - Country:US
Practice Address - Phone:724-772-8000
Practice Address - Fax:724-772-8040
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038951E207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016475970005Medicaid
PA951555LSPMedicare ID - Type Unspecified
PA0016475970005Medicaid