Provider Demographics
NPI:1114922630
Name:KANNAEGANTI, PRASAD VENKATA (MD)
Entity Type:Individual
Prefix:
First Name:PRASAD
Middle Name:VENKATA
Last Name:KANNAEGANTI
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 1:1600 WATERS RIDGE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6039
Mailing Address - Country:US
Mailing Address - Phone:972-219-0558
Mailing Address - Fax:214-466-7237
Practice Address - Street 1:6331 BOULEVARD 26
Practice Address - Street 2:SUITE 220
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-1590
Practice Address - Country:US
Practice Address - Phone:817-628-0284
Practice Address - Fax:817-628-0288
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1701207RN0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX289661501Medicaid
TX289661501Medicaid
NM343426000Medicare ID - Type Unspecified