Provider Demographics
NPI:1376742163
Name:DANDOLU, BHAKTAVATHSALA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:BHAKTAVATHSALA
Middle Name:REDDY
Last Name:DANDOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:B.
Other - Middle Name:REDDY
Other - Last Name:DANDOLU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1701 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-671-2395
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-5150
Practice Address - Fax:702-384-6493
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06622600208G00000X
CAC51992208G00000X
NV14614208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH 93812Medicare UPIN
NVHG569ZMedicare PIN