Provider Demographics
NPI:1073621793
Name:NOOTHETI, SAGAR VIDYA (MD)
Entity Type:Individual
Prefix:
First Name:SAGAR
Middle Name:VIDYA
Last Name:NOOTHETI
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 1:4700 BERWYN HOUSE ROAD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4706
Mailing Address - Country:US
Mailing Address - Phone:301-345-0077
Mailing Address - Fax:301-345-4489
Practice Address - Street 1:4700 BERWYN HOUSE ROAD
Practice Address - Street 2:SUITE 108
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-4706
Practice Address - Country:US
Practice Address - Phone:301-345-0077
Practice Address - Fax:301-345-4489
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD24694207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
146085200OtherDEPT OF LABOR
MD134251700Medicaid
6480SVOtherBC/MD
62308OtherCIGNA
23222OtherAETNA
28320001OtherBC/FED
60054OtherAETNA
146085200OtherDEPT OF LABOR
28320001OtherBC/FED