Provider Demographics
NPI:1275534711
Name:MANDAVA, NAGESWARA R (MD)
Entity Type:Individual
Prefix:
First Name:NAGESWARA
Middle Name:R
Last Name:MANDAVA
Suffix:
Gender:M
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:PO BOX 740008
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-0008
Mailing Address - Country:US
Mailing Address - Phone:718-670-5202
Mailing Address - Fax:718-670-5312
Practice Address - Street 1:14601 45TH AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2200
Practice Address - Country:US
Practice Address - Phone:718-670-5202
Practice Address - Fax:718-670-5312
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1653212086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01124258Medicaid
NY01124258Medicaid
E38238Medicare UPIN