Healthcare Provider Details

I. General information

NPI: 1689643561
Provider Name (Legal Business Name): THOMAS DANIEL JAGGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BROAD ST
WAVERLY NY
14892-1320
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 607-565-2177
  • Fax: 607-565-2064
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000604
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV003009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: