Healthcare Provider Details

I. General information

NPI: 1043267917
Provider Name (Legal Business Name): VENKAT R NIMMAGADDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HAVEN DR
DOTHAN AL
36301-2919
US

IV. Provider business mailing address

207 HAVEN DR
DOTHAN AL
36301-2919
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-3319
  • Fax: 334-793-2291
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number27452
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier51538580
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBCBS ALABAMA
# 2
Identifier051557983
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: