Provider Demographics
NPI:1063779601
Name:SANNAGOWDARA, KUMAR R (M D)
Entity type:Individual
Prefix:DR
First Name:KUMAR
Middle Name:R
Last Name:SANNAGOWDARA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-246-6800
Mailing Address - Fax:414-246-6405
Practice Address - Street 1:9000 W SURA LN
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3477
Practice Address - Country:US
Practice Address - Phone:414-246-6800
Practice Address - Fax:414-246-6405
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI572632084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063779601Medicaid
WI1063779601Medicaid