Provider Demographics
NPI:1205827680
Name:BASAVARAJU, NERLIGE (MD)
Entity Type:Individual
Prefix:MR
First Name:NERLIGE
Middle Name:
Last Name:BASAVARAJU
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 1:45 MAIN ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1000
Mailing Address - Country:US
Mailing Address - Phone:866-662-4560
Mailing Address - Fax:347-328-0333
Practice Address - Street 1:45 MAIN ST
Practice Address - Street 2:SUITE 408
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1000
Practice Address - Country:US
Practice Address - Phone:866-662-4560
Practice Address - Fax:347-328-0333
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117319207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02229674Medicaid
NYB12659Medicare UPIN
NY53P481Medicare ID - Type Unspecified