Basic Information
| Provider Information | |||||||||
| NPI: | 1932365251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAGADISH | ||||||||
| FirstName: | ANUBHAV | ||||||||
| MiddleName: | PUTTANNIAH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 N LITCHFIELD RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853951215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232421231 | ||||||||
| FaxNumber: | 6232421232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 N LITCHFIELD RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853951215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232421231 | ||||||||
| FaxNumber: | 6232421232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036136700 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | 036136700 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | 59580 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 036-136700 | 05 | IL | MEDICAID |