Provider Demographics
NPI:1366689028
Name:MARAGONDANAHALLI, LAKSHMANGOWDA (M D)
Entity Type:Individual
Prefix:
First Name:LAKSHMANGOWDA
Middle Name:
Last Name:MARAGONDANAHALLI
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5717
Mailing Address - Country:US
Mailing Address - Phone:864-261-1800
Mailing Address - Fax:
Practice Address - Street 1:819 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5717
Practice Address - Country:US
Practice Address - Phone:864-261-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC325366Medicaid
SCCJ2703OtherRR MEDICARE
SCP00892002OtherRR MEDICARE
SC325366Medicaid