Provider Demographics
NPI:1669411807
Name:JAGGER, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JAGGER
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:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:574-472-6746
Practice Address - Street 1:611 E DOUGLAS
Practice Address - Street 2:SUITE 309
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1467
Practice Address - Country:US
Practice Address - Phone:574-252-2640
Practice Address - Fax:574-252-2650
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023464208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000269222OtherBCBS
IN100222270AMedicaid
INF18388Medicare UPIN