Provider Demographics
NPI:1023048915
Name:NAGIREDDI, VENKATA (MD)
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:
Last Name:NAGIREDDI
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 1:1463 HIGHWAY 61
Mailing Address - Street 2:SUITE C
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4101
Mailing Address - Country:US
Mailing Address - Phone:636-937-2755
Mailing Address - Fax:636-933-2910
Practice Address - Street 1:1463 US HIGHWAY 61
Practice Address - Street 2:SUITE C
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-937-2755
Practice Address - Fax:636-933-2910
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004006669208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207557505Medicaid
MO002014730Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBR
MOI18380Medicare UPIN