Provider Demographics
NPI:1215282025
Name:NANDA, MITALI (MD)
Entity type:Individual
Prefix:DR
First Name:MITALI
Middle Name:
Last Name:NANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 QUIETGROVE RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-2984
Mailing Address - Country:US
Mailing Address - Phone:347-726-1959
Mailing Address - Fax:
Practice Address - Street 1:515 STONECREST PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6826
Practice Address - Country:US
Practice Address - Phone:615-223-1550
Practice Address - Fax:615-223-1331
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000053102208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017916Medicaid