Provider Demographics
NPI:1861870412
Name:DHANOA, JUGRAJ S (MD)
Entity type:Individual
Prefix:
First Name:JUGRAJ
Middle Name:S
Last Name:DHANOA
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 1:2406 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1008
Mailing Address - Country:US
Mailing Address - Phone:502-775-1211
Mailing Address - Fax:502-398-0041
Practice Address - Street 1:2406 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1008
Practice Address - Country:US
Practice Address - Phone:502-775-1211
Practice Address - Fax:502-398-0041
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51927207R00000X
FLME157147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty