Provider Demographics
NPI:1952453359
Name:MENDONCA, NAYANTARA (MD)
Entity Type:Individual
Prefix:DR
First Name:NAYANTARA
Middle Name:
Last Name:MENDONCA
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 1:985 PRINCE FREDERICK BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4020
Mailing Address - Country:US
Mailing Address - Phone:410-535-2005
Mailing Address - Fax:410-535-4850
Practice Address - Street 1:985 PRINCE FREDERICK BLVD STE 201
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3492
Practice Address - Country:US
Practice Address - Phone:410-535-2005
Practice Address - Fax:410-535-4850
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD62544302OtherCAREFIRST OF MARYLAND
MDP00256094OtherRAILROAD MEDICARE
MD402561000Medicaid
MD2129823OtherMAMSI HMO
MD7411517OtherAETNA NON-HMO
MD3640951OtherAETNA HMO
DCC0410033OtherCAREFIRST OF DC
MDH85519Medicare UPIN
MD022LJ130Medicare ID - Type UnspecifiedMEDICARE NUMBER