Provider Demographics
NPI:1720196579
Name:NANDALUR, NARAYANA REDDI (MD)
Entity Type:Individual
Prefix:
First Name:NARAYANA
Middle Name:REDDI
Last Name:NANDALUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NARAYANA
Other - Middle Name:N
Other - Last Name:REDDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:43171 DALCOMA DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6307
Mailing Address - Country:US
Mailing Address - Phone:586-263-9600
Mailing Address - Fax:586-263-9336
Practice Address - Street 1:43171 DALCOMA DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6307
Practice Address - Country:US
Practice Address - Phone:586-263-9600
Practice Address - Fax:586-263-9336
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049885207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
0605005782OtherBCBS
MI103408167Medicaid
MI103408167Medicaid
0605005782OtherBCBS