Healthcare Provider Details

I. General information

NPI: 1457092769
Provider Name (Legal Business Name): BHAVANA NANGUNURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HARSHITA NANGUNURI

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11958 W BROAD ST
RICHMOND VA
23233-1007
US

IV. Provider business mailing address

PO BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-360-4669
  • Fax: 804-364-6521
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.173927
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101289108
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: