Provider Demographics
NPI:1023201241
Name:VIJAYALAKSHMI NANDIMANDALAM, M.D., P.A.
Entity Type:Organization
Organization Name:VIJAYALAKSHMI NANDIMANDALAM, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-640-4700
Mailing Address - Street 1:1211 E 6TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4095
Mailing Address - Country:US
Mailing Address - Phone:903-640-4700
Mailing Address - Fax:903-640-1975
Practice Address - Street 1:1211 E 6TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4095
Practice Address - Country:US
Practice Address - Phone:903-640-4700
Practice Address - Fax:903-640-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195422401Medicaid
00Z067Medicare PIN
TX195422401Medicaid