Provider Demographics
NPI:1194982777
Name:NEMARUGOMMULA, VISHAL (MBBS)
Entity type:Individual
Prefix:DR
First Name:VISHAL
Middle Name:
Last Name:NEMARUGOMMULA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:DR
Other - First Name:VISHAL
Other - Middle Name:
Other - Last Name:NEMARUGOMMULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5460 BABCOCK RD STE 120-C
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3901
Mailing Address - Country:US
Mailing Address - Phone:210-753-0744
Mailing Address - Fax:210-783-8444
Practice Address - Street 1:5460 BABCOCK RD STE 120-C
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3901
Practice Address - Country:US
Practice Address - Phone:210-753-0744
Practice Address - Fax:210-783-8444
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0134208M00000X, 207Q00000X
390200000X
MI4301092589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342290909Medicaid