Provider Demographics
NPI:1487768917
Name:PATIL, JAGANNATH (MD)
Entity type:Individual
Prefix:
First Name:JAGANNATH
Middle Name:
Last Name:PATIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6751
Mailing Address - Country:US
Mailing Address - Phone:618-465-8829
Mailing Address - Fax:618-465-5599
Practice Address - Street 1:4 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-465-8829
Practice Address - Fax:618-465-5599
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360913522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG04420Medicare UPIN