Provider Demographics
NPI:1023081676
Name:NANDYALA, MALLIKARJUNA (MD)
Entity type:Individual
Prefix:DR
First Name:MALLIKARJUNA
Middle Name:
Last Name:NANDYALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14749 WATERCHASE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3318
Mailing Address - Country:US
Mailing Address - Phone:813-884-0222
Mailing Address - Fax:813-884-0080
Practice Address - Street 1:13642 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9638
Practice Address - Country:US
Practice Address - Phone:813-884-0222
Practice Address - Fax:813-884-0080
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2509053OtherAETNA
FL110244550OtherRAILROAD MEDICARE
FL113934OtherAMERIGROUP
FL250560600Medicaid
FL243309OtherAVMED
FL31236OtherBLUE CROSS BLUE SHIELD
FLME0070271OtherMEDICAL STATE LICENSE
FL2513301OtherGHI
FL139275BJOtherPREFERRED CARE
FL169930OtherSTAYWELL
FL2513301OtherGHI
FL31236XMedicare PIN