Provider Demographics
NPI:1629381611
Name:NAGOTU KAMBAGIRI, SHARADA (MD)
Entity Type:Individual
Prefix:
First Name:SHARADA
Middle Name:
Last Name:NAGOTU KAMBAGIRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHARADA
Other - Middle Name:
Other - Last Name:NAGOTU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2600
Practice Address - Fax:417-820-2100
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126351207R00000X, 208M00000X
MO2014044152207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629381611Medicaid
MO132680614Medicare PIN