Healthcare Provider Details

I. General information

NPI: 1285615583
Provider Name (Legal Business Name): PRADEEP NAGARAJU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD SUITE 407
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

20952 E 12 MILE RD SUITE 200
SAINT CLAIR SHORES MI
48081-3200
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-0638
  • Fax: 248-355-1449
Mailing address:
  • Phone: 586-771-4820
  • Fax: 586-771-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301083042
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number4301083042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: