Provider Demographics
NPI:1750467494
Name:NIMMAGADDA, NAGABHUSHANA
Entity Type:Individual
Prefix:
First Name:NAGABHUSHANA
Middle Name:
Last Name:NIMMAGADDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 HEMPSTEAD TURNPIKE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554
Mailing Address - Country:US
Mailing Address - Phone:516-542-1090
Mailing Address - Fax:516-794-8165
Practice Address - Street 1:80 MARCUS DR
Practice Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4230
Practice Address - Country:US
Practice Address - Phone:631-391-7887
Practice Address - Fax:631-454-4163
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149316207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00763502Medicaid
NY00763502Medicaid
NYG400009859Medicare PIN