Provider Demographics
NPI:1447327085
Name:JAGANATHAN, SUDHA PRASAD (MD)
Entity type:Individual
Prefix:
First Name:SUDHA
Middle Name:PRASAD
Last Name:JAGANATHAN
Suffix:
Gender:F
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:PO BOX 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-301-0124
Mailing Address - Fax:859-301-0699
Practice Address - Street 1:711 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3439
Practice Address - Country:US
Practice Address - Phone:859-301-0124
Practice Address - Fax:859-301-0699
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090787207R00000X
KY58033207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2873412Medicaid
OH2873412Medicaid
OHH381890Medicare PIN