Provider Demographics
NPI:1437106614
Name:BANALA, DWARAKNADH R (MD)
Entity Type:Individual
Prefix:DR
First Name:DWARAKNADH
Middle Name:R
Last Name:BANALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3016 PALERMO CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6527
Mailing Address - Country:US
Mailing Address - Phone:352-383-8209
Mailing Address - Fax:352-383-8209
Practice Address - Street 1:620 S LAKE ST
Practice Address - Street 2:SUITE #6
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6059
Practice Address - Country:US
Practice Address - Phone:352-365-0099
Practice Address - Fax:352-315-0578
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME80590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2729423 00Medicaid
FLG83370Medicare UPIN
FLU5896AMedicare PIN