Provider Demographics
NPI:1659378693
Name:NAGRA, AJIT S (MD)
Entity Type:Individual
Prefix:
First Name:AJIT
Middle Name:S
Last Name:NAGRA
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 1:100 MERCY WAY
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-781-2727
Mailing Address - Fax:417-621-0571
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:417-621-0571
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108392207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08220357OtherBCBS GRP#
IL900068033OtherTAX-ID#
IL900068033OtherTAX-ID#
IL207465Medicare PIN