Provider Demographics
NPI:1033199955
Name:PUSALAVIDYASAGAR, SNIGDHASMRITHI SAGAR (MBBS)
Entity Type:Individual
Prefix:
First Name:SNIGDHASMRITHI
Middle Name:SAGAR
Last Name:PUSALAVIDYASAGAR
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 276
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-624-0999
Mailing Address - Fax:612-625-2174
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:SUITE 106
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:612-273-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43341207R00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110010436Medicare ID - Type Unspecified
MN290000530Medicare ID - Type Unspecified
H36398Medicare UPIN