Provider Demographics
NPI:1790743755
Name:JAGADEESAN, UDAYA B (MD)
Entity Type:Individual
Prefix:
First Name:UDAYA
Middle Name:B
Last Name:JAGADEESAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:770 CONVERSE ST
Practice Address - Street 2:JGS ADMINISTRATIVE SERVICES
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106
Practice Address - Country:US
Practice Address - Phone:413-567-6213
Practice Address - Fax:413-565-2975
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210498207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0193631Medicaid
MAA33747Medicare PIN
MA0193631Medicaid
P00357150Medicare PIN