Provider Demographics
NPI:1124092986
Name:JAGOO, GAUTAM (MD)
Entity type:Individual
Prefix:MR
First Name:GAUTAM
Middle Name:
Last Name:JAGOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 SUNDOWN DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3552
Mailing Address - Country:US
Mailing Address - Phone:404-805-4947
Mailing Address - Fax:404-501-5707
Practice Address - Street 1:1700 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2195
Practice Address - Country:US
Practice Address - Phone:770-979-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30BDMGTMedicare ID - Type Unspecified
I37734Medicare UPIN