Provider Demographics
NPI:1821234501
Name:SRINIVASARAGHAVAN, JAGANNATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JAGANNATHAN
Middle Name:
Last Name:SRINIVASARAGHAVAN
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 1:247 LAKE INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-6184
Mailing Address - Country:US
Mailing Address - Phone:618-351-9989
Mailing Address - Fax:
Practice Address - Street 1:247 LAKE INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-6184
Practice Address - Country:US
Practice Address - Phone:618-351-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-0570492084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry