Provider Demographics
NPI:1144302043
Name:NAGALLA, ASHA LATA (MD)
Entity type:Individual
Prefix:DR
First Name:ASHA LATA
Middle Name:
Last Name:NAGALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ASHA LATA
Other - Middle Name:
Other - Last Name:NAGALLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1331 BELFIORE WAY
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-8131
Mailing Address - Country:US
Mailing Address - Phone:407-810-3407
Mailing Address - Fax:
Practice Address - Street 1:1331 BELFIORE WAY
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-8131
Practice Address - Country:US
Practice Address - Phone:407-810-3407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0079170207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260158300Medicaid
C36317Medicare UPIN
51870YMedicare ID - Type Unspecified