Provider Demographics
NPI:1013998160
Name:VENNA, NAGAGOPAL (MD)
Entity Type:Individual
Prefix:DR
First Name:NAGAGOPAL
Middle Name:
Last Name:VENNA
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:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-7643
Mailing Address - Fax:617-726-6991
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WAC 835
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-5533
Practice Address - Fax:617-726-6991
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA417082084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2070057Medicaid
MA712756OtherTUFTS HEALTH PLAN
MAM09965OtherBCBS MA
MAM09965Medicare ID - Type Unspecified
A67073Medicare UPIN