Basic Information
| Provider Information | |||||||||
| NPI: | 1205872116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAGLAN | ||||||||
| FirstName: | SANDEEP | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704272845 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704272845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 057561 | GA | N | Other Service Providers | Specialist | 207RN0300X | GA057561 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 955029596AA | 05 | GA | MEDICAID | 955029596O | 05 | GA | MEDICAID | 057561 | 01 | GA | STATE LICENSE | OTHER | 955029596F | 05 | GA | MEDICAID | 955029596W | 05 | GA | MEDICAID | 955029596M | 05 | GA | MEDICAID | 955029596Q | 05 | GA | MEDICAID | 955029596L | 05 | GA | MEDICAID | 955029596S | 05 | GA | MEDICAID | 955029596A | 05 | GA | MEDICAID | 955029596B | 05 | GA | MEDICAID | 955029596C | 05 | GA | MEDICAID | 955029596I | 05 | GA | MEDICAID | 955029596N | 05 | GA | MEDICAID | 955029596R | 05 | GA | MEDICAID | 955029596T | 05 | GA | MEDICAID | 955029596U | 05 | GA | MEDICAID | 955029596X | 05 | GA | MEDICAID | 955029596Y | 05 | GA | MEDICAID | 955029596P | 05 | GA | MEDICAID | 955029596V | 05 | GA | MEDICAID |