Healthcare Provider Details

I. General information

NPI: 1174688683
Provider Name (Legal Business Name): ANEGUNDI K NAGENDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 BIELBY RD
LAWRENCEBURG IN
47025-1056
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-212-0497
  • Fax: 812-577-0791
Mailing address:
  • Phone: 859-212-0497
  • Fax: 812-577-0791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number17471
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01087838A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: