Healthcare Provider Details

I. General information

NPI: 1770542276
Provider Name (Legal Business Name): GURUMURTHAIAH V NAGABHUSHANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: G V NAGA MD

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 CANISTEO ST
HORNELL NY
14843
US

IV. Provider business mailing address

470 CANISTEO ST
HORNELL NY
14843
US

V. Phone/Fax

Practice location:
  • Phone: 607-324-4414
  • Fax: 607-324-6072
Mailing address:
  • Phone: 607-324-4414
  • Fax: 607-324-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number1261591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: