Provider Demographics
NPI:1376983767
Name:MAMBALAM, NITYA BANDLA (MD,)
Entity Type:Individual
Prefix:
First Name:NITYA
Middle Name:BANDLA
Last Name:MAMBALAM
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2256
Mailing Address - Country:US
Mailing Address - Phone:484-526-5210
Mailing Address - Fax:484-526-5237
Practice Address - Street 1:1417 8TH AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-2256
Practice Address - Country:US
Practice Address - Phone:484-526-5210
Practice Address - Fax:484-526-5237
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4582392084V0102X
MO2013021634282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013021634OtherMISSOURI TEMPORARY LICENSE