Healthcare Provider Details

I. General information

NPI: 1972576940
Provider Name (Legal Business Name): JAGANNADHA RAO AVASARALA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE KY CLINIC J401
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

740 S LIMESTONE KY CLINIC J401
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5661
  • Fax:
Mailing address:
  • Phone: 859-323-5661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2008028207
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number36752
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number51916
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: