Healthcare Provider Details

I. General information

NPI: 1659769891
Provider Name (Legal Business Name): CHAMPAKA NAGARAJU D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 05/03/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 GRAPE AVE
SAINT CLOUD FL
34769-3965
US

IV. Provider business mailing address

1877 FORTUNE RD
KISSIMMEE FL
34744-4428
US

V. Phone/Fax

Practice location:
  • Phone: 407-943-8600
  • Fax: 407-932-5153
Mailing address:
  • Phone: 407-943-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21014
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: