Provider Demographics
NPI:1659398386
Name:NANDURI, VISALA V (MD)
Entity Type:Individual
Prefix:DR
First Name:VISALA
Middle Name:V
Last Name:NANDURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13 BLUE BIRD CT
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2127
Mailing Address - Country:US
Mailing Address - Phone:973-992-0658
Mailing Address - Fax:973-992-6655
Practice Address - Street 1:315 E NORTHFIELD RD
Practice Address - Street 2:SUITE # 1D
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4896
Practice Address - Country:US
Practice Address - Phone:973-992-0658
Practice Address - Fax:973-992-6655
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07707100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0110515Medicaid
NJ0110515Medicaid
NJ089960U2HMedicare PIN