Healthcare Provider Details

I. General information

NPI: 1053559906
Provider Name (Legal Business Name): ASHISH VIJAYAKUMAR REGULAGADDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 BROADWAY N
FARGO ND
58122
US

IV. Provider business mailing address

PO BOX 2010
FARGO ND
58122-2784
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3360
  • Fax: 701-234-3868
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number14956
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: