Provider Demographics
NPI:1689722951
Name:NIMMAGADDA, PRAVEEN SRISATYA (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:SRISATYA
Last Name:NIMMAGADDA
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 1:5300 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1463
Mailing Address - Country:US
Mailing Address - Phone:314-877-5989
Mailing Address - Fax:
Practice Address - Street 1:5300 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1463
Practice Address - Country:US
Practice Address - Phone:314-877-5989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1075802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208484105Medicaid
MO107580OtherMEDICAL LICENSE NUMBER
MOG17082Medicare UPIN
MO208484105Medicaid