Provider Demographics
NPI:1881649267
Name:JAGASIA, ISHWAR (MD)
Entity Type:Individual
Prefix:DR
First Name:ISHWAR
Middle Name:
Last Name:JAGASIA
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 1:2200 FORT JESSE RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6286
Mailing Address - Country:US
Mailing Address - Phone:309-452-1788
Mailing Address - Fax:309-862-1302
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 280
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-452-1788
Practice Address - Fax:309-862-1302
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054652*3Medicaid
ILC42441Medicare UPIN
IL036054652*3Medicaid