Provider Demographics
NPI:1861664203
Name:NAYAK, BANNANJE R (MD)
Entity Type:Individual
Prefix:
First Name:BANNANJE
Middle Name:R
Last Name:NAYAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:B
Other - Middle Name:RAVI
Other - Last Name:NAYAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:19830 LAKE CHABOT ROAD
Mailing Address - Street 2:STE C
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546
Mailing Address - Country:US
Mailing Address - Phone:510-886-7348
Mailing Address - Fax:
Practice Address - Street 1:19830 LAKE CHABOT ROAD
Practice Address - Street 2:STE C
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:510-886-7348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34204208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation