Provider Demographics
NPI:1285601278
Name:PONUGOTI, NAGARJUNA R (MD)
Entity type:Individual
Prefix:DR
First Name:NAGARJUNA
Middle Name:R
Last Name:PONUGOTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4779 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4559
Mailing Address - Country:US
Mailing Address - Phone:812-234-2016
Mailing Address - Fax:812-234-2700
Practice Address - Street 1:4779 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4559
Practice Address - Country:US
Practice Address - Phone:812-234-2016
Practice Address - Fax:812-234-2700
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040096207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100252770AMedicaid
F27507Medicare UPIN
IN100252770AMedicaid