Provider Demographics
NPI:1043267917
Name:NIMMAGADDA, VENKAT R (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKAT
Middle Name:R
Last Name:NIMMAGADDA
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 1:1540 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3012
Mailing Address - Country:US
Mailing Address - Phone:334-793-2618
Mailing Address - Fax:334-792-7353
Practice Address - Street 1:1540 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3012
Practice Address - Country:US
Practice Address - Phone:334-793-2618
Practice Address - Fax:334-792-7353
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27452207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051557983OtherID
AL51538580OtherBCBS ALABAMA
I61586Medicare UPIN