Provider Demographics
NPI:1922090190
Name:ANNABATHULA, JAGAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JAGAN
Middle Name:
Last Name:ANNABATHULA
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 1:1709 KY ROUTE 321
Mailing Address - Street 2:STE 3
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-9101
Mailing Address - Country:US
Mailing Address - Phone:606-886-8546
Mailing Address - Fax:606-886-8548
Practice Address - Street 1:7629 KY ROUTE 979
Practice Address - Street 2:
Practice Address - City:GRETHEL
Practice Address - State:KY
Practice Address - Zip Code:41631-6304
Practice Address - Country:US
Practice Address - Phone:606-587-2200
Practice Address - Fax:606-587-2203
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33239207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64018427Medicaid
G67772Medicare UPIN
KY0258116Medicare ID - Type Unspecified
KY0253414Medicare ID - Type Unspecified