Provider Demographics
NPI:1215925656
Name:VALLABHANENI, NAGESWARARAO (MD PSYCHIATRIST)
Entity type:Individual
Prefix:
First Name:NAGESWARARAO
Middle Name:
Last Name:VALLABHANENI
Suffix:
Gender:M
Credentials:MD PSYCHIATRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12831 HICKORY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1828
Mailing Address - Country:US
Mailing Address - Phone:314-966-8746
Mailing Address - Fax:
Practice Address - Street 1:1315 LEHMEN DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-0031
Practice Address - Country:US
Practice Address - Phone:618-826-4571
Practice Address - Fax:618-826-3229
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F30767Medicare UPIN
ILP15541Medicare ID - Type Unspecified