Provider Demographics
NPI:1851690705
Name:SAGAR V.NOOTHETI,M.D.P.A
Entity Type:Organization
Organization Name:SAGAR V.NOOTHETI,M.D.P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-345-0077
Mailing Address - Street 1:4700 BERWYN HOUSE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2474
Mailing Address - Country:US
Mailing Address - Phone:301-345-0077
Mailing Address - Fax:301-345-4489
Practice Address - Street 1:4700 BERWYN HOUSE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2474
Practice Address - Country:US
Practice Address - Phone:301-345-0077
Practice Address - Fax:301-345-4489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOOTHETI,SAGAR VIDYA,M.D
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD24694207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC28320001OtherBC/FED
MD6480SVOtherBC/MD
MD62308OtherCIGNA
MD1345251700Medicaid
DC146085200OtherDEPT.OF LABOR
MD60054OtherAETNA
MD23222OtherAETNA
MD62308OtherCIGNA
C88420Medicare UPIN