Provider Demographics
NPI:1306879119
Name:NANDIGAM, BALA K (MD)
Entity type:Individual
Prefix:
First Name:BALA
Middle Name:K
Last Name:NANDIGAM
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:2400 HARBOR BLVD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5052
Mailing Address - Country:US
Mailing Address - Phone:941-625-6187
Mailing Address - Fax:941-625-7887
Practice Address - Street 1:2400 HARBOR BLVD
Practice Address - Street 2:SUITE 12
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5052
Practice Address - Country:US
Practice Address - Phone:941-625-6187
Practice Address - Fax:941-625-7887
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2013-06-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME48592207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50362Medicare UPIN
FL02151AMedicare PIN