Provider Demographics
NPI:1104002666
Name:SRINAGESH, PRASANNA SAMPURNA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANNA
Middle Name:SAMPURNA
Last Name:SRINAGESH
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 1:824 SAINT MARYS DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3245
Mailing Address - Country:US
Mailing Address - Phone:347-804-4230
Mailing Address - Fax:
Practice Address - Street 1:220 UVALDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4569
Practice Address - Country:US
Practice Address - Phone:912-285-2053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046093207R00000X, 208M00000X
GA66648207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist