Provider Demographics
NPI:1336212554
Name:NALLURI, KRISHNA RAO (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:RAO
Last Name:NALLURI
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 1:10051 LORRAINE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-6001
Mailing Address - Country:US
Mailing Address - Phone:228-868-5493
Mailing Address - Fax:228-868-9930
Practice Address - Street 1:10051 LORRAINE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-6001
Practice Address - Country:US
Practice Address - Phone:228-868-5493
Practice Address - Fax:228-868-9930
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS127222084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014923Medicaid
MS130000159Medicare ID - Type Unspecified
MS09014923Medicaid