Provider Demographics
NPI:1720057433
Name:JAAGOSILD, PRIIT (MD)
Entity Type:Individual
Prefix:
First Name:PRIIT
Middle Name:
Last Name:JAAGOSILD
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:1116 N 16TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2119
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8054
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054247A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11438153OtherCAQH NUMBER
IN20049990Medicaid
IN9397183OtherPHCS PID NUMBER
IN000000351161OtherANTHEM PROVIDER NUMBER
IN9397183OtherPHCS PID NUMBER
IN20049990Medicaid
IN815500B7Medicare PIN
IN185510OMedicare PIN
INP00167197Medicare PIN
IN921480BBBMedicare PIN