Provider Demographics
NPI:1942314703
Name:NAGESH, PRIYAMVADA (MD)
Entity type:Individual
Prefix:DR
First Name:PRIYAMVADA
Middle Name:
Last Name:NAGESH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N WEST AVE,
Mailing Address - Street 2:RECOVERY TECHNOLOGY, SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2179
Mailing Address - Country:US
Mailing Address - Phone:517-780-3336
Mailing Address - Fax:517-796-4561
Practice Address - Street 1:1200 N WEST AVE,
Practice Address - Street 2:RECOVERY TECHNOLOGY, SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-780-3336
Practice Address - Fax:517-796-4561
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0465032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3061977Medicaid
MI260C876120OtherBLUE CROSS BLUE SHIELD
MI0C87612012Medicare ID - Type Unspecified
MI3061977Medicaid