Provider Demographics
NPI:1386835601
Name:NIDADAVOLU, NAGA LAKSHMANA PRASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:NAGA LAKSHMANA
Middle Name:PRASAD
Last Name:NIDADAVOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NAGALAKSHMANA
Other - Middle Name:PRASAD
Other - Last Name:NIDADAVOLU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4741 OLD CANOE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-1400
Mailing Address - Country:US
Mailing Address - Phone:407-818-1664
Mailing Address - Fax:407-818-1654
Practice Address - Street 1:4355 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4828
Practice Address - Country:US
Practice Address - Phone:386-755-1221
Practice Address - Fax:386-755-1219
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAGETP.LSU2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME109423OtherFLORIDA MEDICAL BOARD