Provider Demographics
NPI:1922075464
Name:NANDIMANDALAM, VIJAYALAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:NANDIMANDALAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 E 6TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4095
Mailing Address - Country:US
Mailing Address - Phone:903-640-4700
Mailing Address - Fax:903-640-1975
Practice Address - Street 1:1211 E 6TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4095
Practice Address - Country:US
Practice Address - Phone:903-640-4700
Practice Address - Fax:903-640-1975
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195425701Medicaid
TX195425701Medicaid
I10272Medicare UPIN