Basic Information
Provider Information | |||||||||
NPI: | 1376573014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUBAGUNTA | ||||||||
FirstName: | PRASUNA | ||||||||
MiddleName: | GNANA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRAHMAMDAM | ||||||||
OtherFirstName: | PRASUNA | ||||||||
OtherMiddleName: | G | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1805 HENNEPIN AVE N | ||||||||
Address2: |   | ||||||||
City: | GLENCOE | ||||||||
State: | MN | ||||||||
PostalCode: | 553361416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3208643121 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1805 HENNEPIN AVE N | ||||||||
Address2: |   | ||||||||
City: | GLENCOE | ||||||||
State: | MN | ||||||||
PostalCode: | 553361416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3208643121 | ||||||||
FaxNumber: | 3208647887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2006 | ||||||||
LastUpdateDate: | 11/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 055401 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 64422 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | N1617 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 208812201 | 05 | TX |   | MEDICAID | 8CF471 | 01 | TX | BCBS | OTHER |