Healthcare Provider Details

I. General information

NPI: 1154327740
Provider Name (Legal Business Name): JEFFREY D AGRICOLA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 E CARMEL DR STE D
CARMEL IN
46032-2609
US

IV. Provider business mailing address

3731 GUION ROAD SUITE C
INDIANAPOLIS IN
46222-7604
US

V. Phone/Fax

Practice location:
  • Phone: 317-846-4111
  • Fax: 317-846-1767
Mailing address:
  • Phone: 317-931-0661
  • Fax: 317-927-0924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000947A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: