Healthcare Provider Details

I. General information

NPI: 1598109753
Provider Name (Legal Business Name): RADHIKA NAGA AYYAGARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRIME HEALTHCARE PC 44 DALE RD
AVON CT
06001-4320
US

IV. Provider business mailing address

30 JORDAN LN
WETHERSFIELD CT
06109-1278
US

V. Phone/Fax

Practice location:
  • Phone: 860-674-8830
  • Fax: 860-674-8984
Mailing address:
  • Phone: 602-630-2538
  • Fax: 860-263-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number63734
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: