Provider Demographics
NPI:1689643561
Name:JAGGER, THOMAS DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DANIEL
Last Name:JAGGER
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:150 BROAD ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892-1320
Practice Address - Country:US
Practice Address - Phone:607-565-2177
Practice Address - Fax:607-565-2064
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000604152W00000X
NYTUV003009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
PA001844952001Medicaid
NY02144190Medicaid
NY410045675OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
NYCC5958Medicare ID - Type Unspecified