=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417510603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNE N JAGUNLA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2019
-----------------------------------------------------
Last Update Date | 10/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 CIVIC CENTER BLVD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-405-7839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 INVERNESS DR
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08753-6315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-405-7839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD477952
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------