Provider Demographics
NPI:1336328012
Name:ORLANDO PRIMARY CARE PA
Entity Type:Organization
Organization Name:ORLANDO PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATESWARA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NANDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-298-0912
Mailing Address - Street 1:6200 SILVER STAR RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-4245
Mailing Address - Country:US
Mailing Address - Phone:407-298-0912
Mailing Address - Fax:407-298-1750
Practice Address - Street 1:6200 SILVER STAR RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-4245
Practice Address - Country:US
Practice Address - Phone:407-298-0912
Practice Address - Fax:407-298-1750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2013-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255449600Medicaid
G82667Medicare UPIN
FL255449600Medicaid