Provider Demographics
NPI:1972576940
Name:AVASARALA, JAGANNADHA RAO (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JAGANNADHA
Middle Name:RAO
Last Name:AVASARALA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S LIMESTONE KY CLINIC J401
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5661
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE KY CLINIC J401
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080282072084N0400X
SC367522084N0400X
KY519162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ0031CMedicaid
MO1972576940Medicaid
MO1972576940OtherTRIWEST
MO132470052Medicare PIN
MO1972576940Medicaid
SCQ0031CMedicaid