Provider Demographics
NPI:1255560918
Name:JAGTAP, MANDAR R (DO)
Entity type:Individual
Prefix:DR
First Name:MANDAR
Middle Name:R
Last Name:JAGTAP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-1470
Mailing Address - Country:US
Mailing Address - Phone:662-287-5218
Mailing Address - Fax:662-286-3186
Practice Address - Street 1:1310 HIGHWAY 72 E
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6524
Practice Address - Country:US
Practice Address - Phone:662-594-4123
Practice Address - Fax:625-942-2966
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13840207RC0000X
MS25097207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1H1365OtherMS MEDICARE INDIVIDUAL
MS03005201Medicaid