Provider Demographics
NPI:1376541581
Name:VISHAKANTAIAH, NAGARAJA (MD)
Entity Type:Individual
Prefix:DR
First Name:NAGARAJA
Middle Name:
Last Name:VISHAKANTAIAH
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 1:4692 BROWNSBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3410
Mailing Address - Country:US
Mailing Address - Phone:336-251-1114
Mailing Address - Fax:336-251-1117
Practice Address - Street 1:4692 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3410
Practice Address - Country:US
Practice Address - Phone:336-251-1114
Practice Address - Fax:336-251-1117
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101840596207Q00000X
NC2018-02625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010052360Medicaid
VA003619B65Medicare ID - Type Unspecified