Provider Demographics
NPI:1346777026
Name:TANDAN, NITIN
Entity Type:Individual
Prefix:
First Name:NITIN
Middle Name:
Last Name:TANDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2483
Mailing Address - Country:US
Mailing Address - Phone:504-842-0879
Mailing Address - Fax:
Practice Address - Street 1:751 N RUTLEDGE ST STE 1100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125073449207R00000X
390200000X
LA326422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program