MEDICARE: DR. HERAGANAHALLY NAGEGOWDA SUNDAR RAJ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4121	NV
2	207QA0505X	Adult Medicine Physician	4121	NV
3	208D00000X	General Practice Physician	MD 4121	NV

General Provider Information

NPI Number	:	1922306497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HERAGANAHALLY NAGEGOWDA SUNDAR RAJ MD

Provider Business Mailing Address
First Line	:	6255 SHARLANDS AVE
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89523-2882
Country	:	US
Telephone Number	:	775-770-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 N DECATUR BLVD
Second Line	:	STE 5
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2497
Country	:	US
Telephone Number	:	702-785-3005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2011
Last Update Date	:	09/04/2024

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