Provider Demographics
NPI:1104813401
Name:NIMMAGADDA, PHANI R (MD)
Entity type:Individual
Prefix:DR
First Name:PHANI
Middle Name:R
Last Name:NIMMAGADDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2715
Mailing Address - Country:US
Mailing Address - Phone:631-724-4110
Mailing Address - Fax:631-366-2669
Practice Address - Street 1:12 MANOR RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2715
Practice Address - Country:US
Practice Address - Phone:631-724-4110
Practice Address - Fax:631-366-2669
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-02
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201565-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine