Provider Demographics
NPI:1730136870
Name:JAGANNATH, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:JAGANNATH
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:PO BOX 18563
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8563
Mailing Address - Country:US
Mailing Address - Phone:919-783-4887
Mailing Address - Fax:919-783-4887
Practice Address - Street 1:2601 LAKE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6688
Practice Address - Country:US
Practice Address - Phone:919-783-4888
Practice Address - Fax:919-783-4887
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-02088207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD983200900Medicaid
MD983200900Medicaid
MDKR6833QQMedicare ID - Type Unspecified