Provider Demographics
NPI:1316142268
Name:NAGALLA, SUBHASH K (MD)
Entity type:Individual
Prefix:
First Name:SUBHASH
Middle Name:K
Last Name:NAGALLA
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 1:420 E 6TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4537
Mailing Address - Country:US
Mailing Address - Phone:432-888-9001
Mailing Address - Fax:324-888-9002
Practice Address - Street 1:420 E 6TH ST STE 102
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4537
Practice Address - Country:US
Practice Address - Phone:432-888-9001
Practice Address - Fax:324-888-9002
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126261208600000X
FLME98793208600000X
PAMD435582208600000X
TXP4790208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD435582OtherMEDICAL LICENSE
TXP4790OtherMEDICAL LICENSE
IL036126261OtherMEDICAL LICENSE
FLME98793OtherMEDICAL LICENSE