Provider Demographics
NPI:1508989260
Name:KONERU, NAGENDRA SAI (MD)
Entity type:Individual
Prefix:
First Name:NAGENDRA
Middle Name:SAI
Last Name:KONERU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:KONERU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI507382085R0001X
IA397412085R0001X
IL0361164532085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34936900Medicaid
IA1316231012Medicaid
IA1316231012Medicaid