1114102225 NPI number — DR. NANDAKISHORE NEMARUGOMMULA MD

Table of content: DR. NANDAKISHORE NEMARUGOMMULA MD (NPI 1114102225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114102225 NPI number — DR. NANDAKISHORE NEMARUGOMMULA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEMARUGOMMULA
Provider First Name:
NANDAKISHORE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114102225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 W OAKLAWN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78064-4033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-569-8940
Provider Business Mailing Address Fax Number:
830-569-8527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 10TH STREET
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
FLORESVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78114-3167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-393-9390
Provider Business Practice Location Address Fax Number:
830-393-9399
Provider Enumeration Date:
01/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  N1014 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202000001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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