Provider Demographics
NPI:1427383512
Name:MALLIKARJUNA NANDYALA MD PA
Entity type:Organization
Organization Name:MALLIKARJUNA NANDYALA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MALLIKARJUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANDYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-884-0222
Mailing Address - Street 1:14749 WATERCHASE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3318
Mailing Address - Country:US
Mailing Address - Phone:813-884-0222
Mailing Address - Fax:813-884-0080
Practice Address - Street 1:8313 W HILLSBOROUGH AVE STE 300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3819
Practice Address - Country:US
Practice Address - Phone:813-884-0222
Practice Address - Fax:813-884-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250560600Medicaid
FL110244550OtherRAILROAD MEDICARE
FLME0070271OtherMEDICAL STATE LICENSE
FLG16372Medicare UPIN
FL250560600Medicaid