Basic Information
| Provider Information | |||||||||
| NPI: | 1578724977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEGANATHAN | ||||||||
| FirstName: | NIRANJAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11234 ANDERSON ST RM 1516 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | 9095580429 | ||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST RM 1516 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | 9095580429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A144063 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | A144063 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | A144063 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 206147 | 01 | IL | MEDICARE PTAN GROUP | OTHER | F400306639 | 01 | IL | MEDICARE PTAN INDIVIDUAL | OTHER |