Provider Demographics
NPI:1538189329
Name:NAGANNA, GOURISHANKAR (MD)
Entity type:Individual
Prefix:DR
First Name:GOURISHANKAR
Middle Name:
Last Name:NAGANNA
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 1:686 POOLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6177
Mailing Address - Country:US
Mailing Address - Phone:443-289-8286
Mailing Address - Fax:
Practice Address - Street 1:686 POOLE RD STE A
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6177
Practice Address - Country:US
Practice Address - Phone:443-289-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059552207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH80319Medicare UPIN
MD190LF466Medicare ID - Type Unspecified