Provider Demographics
NPI:1912918764
Name:RAGHAVAIAH, NIMMAGADDA VEERA (MD)
Entity type:Individual
Prefix:
First Name:NIMMAGADDA
Middle Name:VEERA
Last Name:RAGHAVAIAH
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 1:6005 PARK AVE
Mailing Address - Street 2:#826B
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119
Mailing Address - Country:US
Mailing Address - Phone:901-683-3848
Mailing Address - Fax:901-683-4858
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:#826B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-683-3848
Practice Address - Fax:901-683-4858
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010219208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3196692Medicaid
TN3180297Medicare ID - Type Unspecified
B59418Medicare UPIN