Provider Demographics
NPI:1053338947
Name:JAGDISH LAL MD PA
Entity type:Organization
Organization Name:JAGDISH LAL MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGDISH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-864-7933
Mailing Address - Street 1:PO BOX 25217
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314
Mailing Address - Country:US
Mailing Address - Phone:910-864-7933
Mailing Address - Fax:910-864-3180
Practice Address - Street 1:6977 NEXUS COURT
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2651
Practice Address - Country:US
Practice Address - Phone:910-864-7933
Practice Address - Fax:910-864-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0438753OtherUHC
12136OtherBCBS
084806830OtherTRICARE
NC8912136Medicaid
NC2326252Medicare PIN
NC8912136Medicaid
2274618AMedicare PIN