Provider Demographics
NPI:1407142474
Name:MAGANTI, SOMBABU N (MD)
Entity Type:Individual
Prefix:
First Name:SOMBABU
Middle Name:N
Last Name:MAGANTI
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:STE 3000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-3911
Practice Address - Fax:417-820-3924
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110229352084N0400X
NJ25MA088175002084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00990413OtherRR MCR
AR188731001Medicaid
MO1407142474Medicaid
MO1407142474Medicaid