Provider Demographics
NPI:1548257405
Name:JOHANNIGMAN, JAY A (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:JOHANNIGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4541
Mailing Address - Country:US
Mailing Address - Phone:513-325-2771
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-4504
Practice Address - Country:US
Practice Address - Phone:434-924-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS81932086S0127X
VA01012693582086S0102X
OH35-0571832086S0102X
OH35.0571832086S0127X
IDM-161542086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0705017Medicaid
OH0617236Medicaid
KY64860240Medicaid
A17477Medicare UPIN
OHJ00617232Medicare ID - Type Unspecified