Provider Demographics
NPI:1477647840
Name:DANDADE, TUSHAR P (MD)
Entity Type:Individual
Prefix:
First Name:TUSHAR
Middle Name:P
Last Name:DANDADE
Suffix:
Gender:M
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:2400 UNSER BLVD SE
Practice Address - Street 2:SUITE 18200
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4740
Practice Address - Country:US
Practice Address - Phone:505-253-6200
Practice Address - Fax:505-253-6201
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20030526207VX0000X
NM2003-0526207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65030231Medicaid
H94961Medicare UPIN
348329102Medicare PIN