Healthcare Provider Details

I. General information

NPI: 1225032956
Provider Name (Legal Business Name): LUIS PAGOAGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 GARRETT DR.
MEDINA TN
38355-9641
US

IV. Provider business mailing address

P.O. BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-422-0213
  • Fax: 731-462-5070
Mailing address:
  • Phone: 731-423-8697
  • Fax: 731-256-7634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29003
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: