Healthcare Provider Details

I. General information

NPI: 1407500960
Provider Name (Legal Business Name): JAIDEEP BHARGAVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 04/09/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4021 CANAL STREET
JACKSONVILLE NC
28540
US

IV. Provider business mailing address

4021 CANAL STREET
JACKSONVILLE NC
28540
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-2960
  • Fax:
Mailing address:
  • Phone: 910-450-2960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1407500960
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: