Provider Demographics
NPI:1821036229
Name:ASHOK, NAGASAMUDRA SHAMARAO (MD)
Entity Type:Individual
Prefix:DR
First Name:NAGASAMUDRA
Middle Name:SHAMARAO
Last Name:ASHOK
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 1:880 CALLE AMABLE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-3006
Mailing Address - Country:US
Mailing Address - Phone:818-243-0008
Mailing Address - Fax:
Practice Address - Street 1:229 W 7TH STREET
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583
Practice Address - Country:US
Practice Address - Phone:951-487-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41589207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A415890Medicaid
CAA29414Medicare UPIN
CA00A415890Medicaid