Healthcare Provider Details

I. General information

NPI: 1205399805
Provider Name (Legal Business Name): NAGASASIKANTH R MOPURI MD,MBA,MHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 09/11/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 OLD MARLTON PIKE STE 124
MEDFORD NJ
08055-8772
US

IV. Provider business mailing address

2151 NJ ROUTE 38 APT # 902 E
CHERRY HILL NJ
08002
US

V. Phone/Fax

Practice location:
  • Phone: 888-575-9162
  • Fax: 980-987-4391
Mailing address:
  • Phone: 888-575-9162
  • Fax: 980-987-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD479640
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA1114270
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: