Provider Demographics
NPI:1578558607
Name:PAKKALA, NITHYANANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:NITHYANANDA
Middle Name:
Last Name:PAKKALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:Y.N.
Other - Middle Name:
Other - Last Name:PAKKALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:630 NUCKOLLS RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1532
Mailing Address - Country:US
Mailing Address - Phone:731-658-6011
Mailing Address - Fax:731-658-9884
Practice Address - Street 1:630 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-6011
Practice Address - Fax:731-658-9884
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD9916207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNC46979Medicare UPIN
TN3163629Medicare ID - Type Unspecified