Provider Demographics
NPI:1174728026
Name:NAGALLA, BHANU PRAKASH (MD)
Entity type:Individual
Prefix:
First Name:BHANU
Middle Name:PRAKASH
Last Name:NAGALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N INTERSTATE 35
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-5119
Mailing Address - Country:US
Mailing Address - Phone:940-898-7144
Mailing Address - Fax:940-898-7104
Practice Address - Street 1:3000 N INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-5119
Practice Address - Country:US
Practice Address - Phone:940-898-7144
Practice Address - Fax:940-898-7104
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257074208M00000X
TXQ1687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343072001Medicaid
TX343072001Medicaid