Provider Demographics
NPI:1013042985
Name:NAGALLA, RATNAM BABY (MD)
Entity Type:Individual
Prefix:
First Name:RATNAM
Middle Name:BABY
Last Name:NAGALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2159
Mailing Address - Country:US
Mailing Address - Phone:318-629-0480
Mailing Address - Fax:318-629-0483
Practice Address - Street 1:870 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2159
Practice Address - Country:US
Practice Address - Phone:318-629-0480
Practice Address - Fax:318-629-0483
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.03803R207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1152609Medicaid
54136Medicare PIN
LA54136DC23Medicare PIN
LA1152609Medicaid
LA5DC23Medicare PIN