Healthcare Provider Details

I. General information

NPI: 1093702334
Provider Name (Legal Business Name): NAGIREDDY KAMIREDDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 01/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 MANSFIELD AVE
WILLIMANTIC CT
06226-2091
US

IV. Provider business mailing address

96 MANSFIELD AVE
WILLIMANTIC CT
06226-2091
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7583
  • Fax:
Mailing address:
  • Phone: 860-450-7583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number024233
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24233
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: