Provider Demographics
NPI:1962440594
Name:JAGANNATHAN, SANDHYA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDHYA
Middle Name:
Last Name:JAGANNATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-6817
Mailing Address - Country:US
Mailing Address - Phone:573-426-2572
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHWAY 28 W
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:MO
Practice Address - Zip Code:65013-3405
Practice Address - Country:US
Practice Address - Phone:573-859-3775
Practice Address - Fax:573-859-3997
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004012240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI26381Medicare UPIN