Provider Demographics
NPI:1497043236
Name:RAJEGOWDA, NISCHALA (MD)
Entity Type:Individual
Prefix:
First Name:NISCHALA
Middle Name:
Last Name:RAJEGOWDA
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:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8727
Practice Address - Country:US
Practice Address - Phone:606-523-8620
Practice Address - Fax:606-523-8706
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY510022080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine