Provider Demographics
NPI:1205802436
Name:NANDAMUDI, DEV S (MD)
Entity type:Individual
Prefix:
First Name:DEV
Middle Name:S
Last Name:NANDAMUDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3030 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3819
Mailing Address - Country:US
Mailing Address - Phone:810-385-9559
Mailing Address - Fax:810-385-9515
Practice Address - Street 1:3030 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3819
Practice Address - Country:US
Practice Address - Phone:810-385-9559
Practice Address - Fax:810-385-9515
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301063724208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205802436Medicaid
MI1205802436Medicaid