Provider Demographics
NPI:1851456883
Name:DWIVEDI, JAGANNATH PRASAD (MD)
Entity Type:Individual
Prefix:
First Name:JAGANNATH
Middle Name:PRASAD
Last Name:DWIVEDI
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 1:158 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211
Mailing Address - Country:US
Mailing Address - Phone:718-389-2345
Mailing Address - Fax:
Practice Address - Street 1:158 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211
Practice Address - Country:US
Practice Address - Phone:718-389-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0012381OtherGHI
NY77A551Medicare ID - Type Unspecified
NY0012381OtherGHI