Provider Demographics
NPI:1801865563
Name:DHADWAL, JAGTAR SARUP (MD)
Entity type:Individual
Prefix:
First Name:JAGTAR
Middle Name:SARUP
Last Name:DHADWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:ADMINISTRATIVE RESOURCES
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:250 W BONITA AVE
Practice Address - Street 2:#250
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1863
Practice Address - Country:US
Practice Address - Phone:909-868-6800
Practice Address - Fax:909-868-5379
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA47802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A478020Medicaid
CAWA47802AMedicare PIN
CA110170309Medicare PIN
CAF26257Medicare UPIN
CA00A478020Medicaid