Provider Demographics
NPI:1730576679
Name:GANDAM VENKATA, HIMABINDU (MD,)
Entity type:Individual
Prefix:
First Name:HIMABINDU
Middle Name:
Last Name:GANDAM VENKATA
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:HIMABINDU
Other - Middle Name:
Other - Last Name:TALARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD,
Mailing Address - Street 1:1671 N CLYDE MORRIS BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5590
Mailing Address - Country:US
Mailing Address - Phone:386-274-2977
Mailing Address - Fax:386-274-2362
Practice Address - Street 1:761 STIRLING CENTER PL
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:386-274-2977
Practice Address - Fax:386-274-2362
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME15113207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program