Provider Demographics
NPI:1093702334
Name:KAMIREDDY, NAGIREDDY (MD)
Entity Type:Individual
Prefix:
First Name:NAGIREDDY
Middle Name:
Last Name:KAMIREDDY
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 1:96 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2091
Mailing Address - Country:US
Mailing Address - Phone:860-450-7583
Mailing Address - Fax:
Practice Address - Street 1:96 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2091
Practice Address - Country:US
Practice Address - Phone:860-450-7583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2015-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024233207RP1001X
CT24233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001242338Medicaid
D02434Medicare UPIN
CT001242338Medicaid