Provider Demographics
NPI:1386605657
Name:NUTAKKI, ANUPAMA (MD)
Entity type:Individual
Prefix:
First Name:ANUPAMA
Middle Name:
Last Name:NUTAKKI
Suffix:
Gender:F
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:025-793-2037
Mailing Address - Fax:
Practice Address - Street 1:3048 E BASELINE RD STE 120
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7288
Practice Address - Country:US
Practice Address - Phone:480-505-3276
Practice Address - Fax:480-505-3288
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33663208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ128721Medicaid