Provider Demographics
NPI:1366471898
Name:NANDKUMAR, PREMALATHA
Entity Type:Individual
Prefix:
First Name:PREMALATHA
Middle Name:
Last Name:NANDKUMAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 BIESTERFIELD RD
Mailing Address - Street 2:SUITE G4
Mailing Address - City:ELK GROVE VLG
Mailing Address - State:IL
Mailing Address - Zip Code:60007-7312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 BIESTERFIELD RD
Practice Address - Street 2:SUITE G4
Practice Address - City:ELK GROVE VLG
Practice Address - State:IL
Practice Address - Zip Code:60007-7312
Practice Address - Country:US
Practice Address - Phone:847-981-8856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L83373Medicare PIN