Provider Demographics
NPI:1053635284
Name:SUPRIYA JAGANNATH MD LLC
Entity type:Organization
Organization Name:SUPRIYA JAGANNATH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUPRIYA
Authorized Official - Middle Name:BANAD
Authorized Official - Last Name:JAGANNATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-476-7511
Mailing Address - Street 1:9657 ATTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7400
Mailing Address - Country:US
Mailing Address - Phone:410-476-7511
Mailing Address - Fax:
Practice Address - Street 1:9657 ATTERBURY LN
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7400
Practice Address - Country:US
Practice Address - Phone:410-476-7511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064112207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD618PMedicare UPIN