Provider Demographics
NPI:1477647097
Name:AMBALAVANAR, KANDASAMY (MD)
Entity Type:Individual
Prefix:
First Name:KANDASAMY
Middle Name:
Last Name:AMBALAVANAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7845 OAKWOOD ROAD
Mailing Address - Street 2:103
Mailing Address - City:GLEN BURINE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-766-6447
Mailing Address - Fax:410-766-9780
Practice Address - Street 1:7845 OAKWOOD ROAD
Practice Address - Street 2:103
Practice Address - City:GLEN BURINE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-766-6447
Practice Address - Fax:410-766-9780
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0051596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147400600Medicaid
MDG66520Medicare UPIN
MD625MMedicare ID - Type Unspecified