Provider Demographics
NPI:1588621072
Name:SELAGAMSETTY, MUNNI R (MD)
Entity Type:Individual
Prefix:MRS
First Name:MUNNI
Middle Name:R
Last Name:SELAGAMSETTY
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 1:2875 INTERNATIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:719-389-0070
Mailing Address - Fax:719-389-0071
Practice Address - Street 1:2875 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910
Practice Address - Country:US
Practice Address - Phone:719-389-0070
Practice Address - Fax:719-389-0071
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04018222Medicaid
E71109Medicare UPIN
COCC5244Medicare PIN
CO04018222Medicaid