Provider Demographics
NPI:1295708451
Name:GULLAPALLI, NAGESHWARA R (MBBS, MPH, MBA)
Entity type:Individual
Prefix:DR
First Name:NAGESHWARA
Middle Name:R
Last Name:GULLAPALLI
Suffix:
Gender:M
Credentials:MBBS, MPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E RM 4A100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-587-2451
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 4A100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-587-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11168207R00000X
UT12772344-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504585Medicaid
NV100504585Medicaid
NVI19073Medicare UPIN
NV101388Medicare ID - Type Unspecified