Provider Demographics
NPI:1265813992
Name:VENKATESWARAN, NANDINI (MD)
Entity Type:Individual
Prefix:
First Name:NANDINI
Middle Name:
Last Name:VENKATESWARAN
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 1:1601 TRAPELO RD STE 184
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-7356
Mailing Address - Country:US
Mailing Address - Phone:781-890-1023
Mailing Address - Fax:
Practice Address - Street 1:1601 TRAPELO RD STE 184
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7356
Practice Address - Country:US
Practice Address - Phone:781-890-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA283780207W00000X
FLTRN # 23154390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology