Provider Demographics
NPI:1689607301
Name:JAGODA, JEREMY J (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:JAGODA
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 1:8000 W 110TH ST
Mailing Address - Street 2:STE 150
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2338
Mailing Address - Country:US
Mailing Address - Phone:913-599-6777
Mailing Address - Fax:913-599-3955
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-676-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-533612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00410791OtherRAILROAD MEDICARE
KSP00410959OtherRAILROAD MEDICARE
KSP00410959OtherRAILROAD MEDICARE
KSP00410791OtherRAILROAD MEDICARE
KS209E686Medicare PIN
MOJ01E686Medicare PIN