Provider Demographics
NPI:1740283290
Name:DAGANI, JACOB (M D)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:DAGANI
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6818
Mailing Address - Country:US
Mailing Address - Phone:419-231-3128
Mailing Address - Fax:
Practice Address - Street 1:2555 JUDGE FRAN JAMIESON WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-5998
Practice Address - Country:US
Practice Address - Phone:321-639-5813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.063339207V00000X
FLLL854207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000387949OtherANTHEM BC/BS
OHP00346909OtherRAILROAD CARE
OH0874479Medicaid
OH000000538872OtherANTHEM BC/BS
OH0718035Medicare PIN
OH000000538872OtherANTHEM BC/BS
OH0874479Medicaid