Provider Demographics
NPI:1932320066
Name:JAGADESH, SUNIL KUMAR (MD)
Entity type:Individual
Prefix:
First Name:SUNIL
Middle Name:KUMAR
Last Name:JAGADESH
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 1:1111 N 102ND CT STE 200
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2194
Mailing Address - Country:US
Mailing Address - Phone:402-502-2747
Mailing Address - Fax:402-502-2387
Practice Address - Street 1:1111 N 102ND CT STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2194
Practice Address - Country:US
Practice Address - Phone:402-502-2747
Practice Address - Fax:402-502-2387
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-38484207RN0300X
NE25298207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098684518OtherMEDICARE PTAN
IA414530144OtherMEDICARE PTAN