Provider Demographics
NPI:1780629691
Name:NAGAVALLI, SUDESH (MD)
Entity Type:Individual
Prefix:
First Name:SUDESH
Middle Name:
Last Name:NAGAVALLI
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 1:1524 W LACEY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5965
Mailing Address - Country:US
Mailing Address - Phone:559-583-4697
Mailing Address - Fax:559-583-4600
Practice Address - Street 1:1524 W LACEY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5965
Practice Address - Country:US
Practice Address - Phone:559-583-4503
Practice Address - Fax:559-583-4612
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG74938Medicare UPIN
BV266ZMedicare PIN