Provider Demographics
NPI:1346261229
Name:NAGANNA, VIMALA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIMALA
Middle Name:
Last Name:NAGANNA
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 1:700A POOLE RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-7229
Mailing Address - Country:US
Mailing Address - Phone:410-848-5250
Mailing Address - Fax:
Practice Address - Street 1:700A POOLE RD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7229
Practice Address - Country:US
Practice Address - Phone:410-848-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22567208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB67123Medicare UPIN
MD190L142BMedicare ID - Type Unspecified