Provider Demographics
NPI:1891732467
Name:JAGODZINSKI, MARK ANDREW (PT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:JAGODZINSKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12515 W BELL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9701
Mailing Address - Country:US
Mailing Address - Phone:623-234-4171
Mailing Address - Fax:623-234-4173
Practice Address - Street 1:12515 W BELL RD STE 103
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9701
Practice Address - Country:US
Practice Address - Phone:623-234-4171
Practice Address - Fax:623-234-4173
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5576225100000X, 2251G0304X, 2251H1200X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ738792Medicaid
AZZ106903Medicare PIN
AZ738792Medicaid