Provider Demographics
NPI:1760406359
Name:WALIA, JAG MOHAN S (MD)
Entity Type:Individual
Prefix:
First Name:JAG MOHAN
Middle Name:S
Last Name:WALIA
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 1:320 E FONTANERO ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7529
Mailing Address - Country:US
Mailing Address - Phone:719-866-6218
Mailing Address - Fax:
Practice Address - Street 1:320 E FONTANERO ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7529
Practice Address - Country:US
Practice Address - Phone:719-866-6218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO402872083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO811604OtherMEDICARE GROUP NUMBER