Provider Demographics
NPI:1205842242
Name:AYYAGARI, LAKSHMANA RAO (MD)
Entity Type:Individual
Prefix:
First Name:LAKSHMANA RAO
Middle Name:
Last Name:AYYAGARI
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 1:1165 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3406
Mailing Address - Country:US
Mailing Address - Phone:810-732-5400
Mailing Address - Fax:810-733-1624
Practice Address - Street 1:1165 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3406
Practice Address - Country:US
Practice Address - Phone:810-732-5400
Practice Address - Fax:810-733-1624
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054745174400000X
MI4301106360207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID036054745OtherMEDICAL LICENSE
MI4301106360OtherSTATE MEDICAL LICENSE
IL690280OtherBCBS GROUP ID#
IL036054745OtherIPA ID#
364025739OtherTAX ID
364025739OtherTAX ID
690280Medicare ID - Type Unspecified
IL036054745OtherIPA ID#