Healthcare Provider Details

I. General information

NPI: 1225559016
Provider Name (Legal Business Name): AMIT JAGTIANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

IV. Provider business mailing address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5000
  • Fax:
Mailing address:
  • Phone: 417-761-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2021044466
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2021044466
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMT221089
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: