Provider Demographics
NPI:1073589206
Name:ANMANGANDLA, VIDYASAGAR (MD)
Entity type:Individual
Prefix:
First Name:VIDYASAGAR
Middle Name:
Last Name:ANMANGANDLA
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 1:10583 THEODORE GREEN BLVD
Mailing Address - Street 2:WHITE PLAINS MEDICAL CENTER
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695
Mailing Address - Country:US
Mailing Address - Phone:301-934-9300
Mailing Address - Fax:301-934-6963
Practice Address - Street 1:10583 THEODORE GREEN BLVD
Practice Address - Street 2:WHITE PLAINS MEDICAL CENTER
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:301-934-9300
Practice Address - Fax:301-934-6963
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2012-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0026064207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD769601900Medicaid
669QMedicare ID - Type Unspecified
MDF07208Medicare UPIN