Provider Demographics
NPI:1285615583
Name:NAGARAJU, PRADEEP (MD)
Entity type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:
Last Name:NAGARAJU
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 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:SUITE 407
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-0638
Practice Address - Fax:248-355-1449
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083042208800000X, 2088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPN083042OtherBCBSM LICENCE NUMBER
MI0E06273OtherBCBSM
MI0219690001Medicare NSC
MIPN083042OtherBCBSM LICENCE NUMBER
MI0E06273Medicare PIN