Provider Demographics
NPI:1922202597
Name:JAGANMOHAN, SATHYA (MD)
Entity Type:Individual
Prefix:
First Name:SATHYA
Middle Name:
Last Name:JAGANMOHAN
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 1:3217 MABEL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4022
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9126
Practice Address - Street 1:8001 YOUREE DR STE 540
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2343
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-631-9126
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203683207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.203683OtherSTATE LICENSE
LA1059480Medicaid
LA263505YTS0Medicare PIN