Provider Demographics
NPI:1225122674
Name:NAGARAJ, MYTHILI (MD)
Entity Type:Individual
Prefix:DR
First Name:MYTHILI
Middle Name:
Last Name:NAGARAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3846
Mailing Address - Country:US
Mailing Address - Phone:916-481-4389
Mailing Address - Fax:
Practice Address - Street 1:1651 AVENIDA SELVA
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-1559
Practice Address - Country:US
Practice Address - Phone:714-905-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36300207R00000X
CAC52265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH54900Medicare UPIN
CAH54900Medicare UPIN
KY1497776041Medicare ID - Type Unspecified