Basic Information
Provider Information | |||||||||
NPI: | 1235321233 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAGOS | ||||||||
FirstName: | JAIME | ||||||||
MiddleName: | ANDRES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPT. 453 PO BOX 1000 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8285752625 | ||||||||
FaxNumber: | 8283502174 | ||||||||
Practice Location | |||||||||
Address1: | 98 WILLOW LN | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293071357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645855552 | ||||||||
FaxNumber: | 8645970179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2007 | ||||||||
LastUpdateDate: | 06/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 2011-01327 | NC | N |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   | 207K00000X | 30260 | SC | N |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   | 207K00000X | MD30260 | SC | Y |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | AA23164292 | 01 | SC | MEDICARE PTAN | OTHER | 1881684207 | 05 | NC |   | MEDICAID | 302602 | 05 | SC |   | MEDICAID | NCT474A | 01 | NC | MEDICARE PTAN | OTHER |