Provider Demographics
NPI:1801983390
Name:CHANNAVEERAIAH, NAGANNA (MD, MBA, CPE)
Entity type:Individual
Prefix:
First Name:NAGANNA
Middle Name:
Last Name:CHANNAVEERAIAH
Suffix:
Gender:M
Credentials:MD, MBA, CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 PROFESSIONAL CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4461
Mailing Address - Country:US
Mailing Address - Phone:904-688-3000
Mailing Address - Fax:904-688-3001
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-455-9000
Practice Address - Fax:718-452-6112
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123689207Q00000X
NY276303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1801983390Medicaid
NY1801983390Medicaid
MO1801983390Medicaid
IL036122083-02Medicaid