Provider Demographics
NPI:1356386767
Name:NANDISH, BANATHALLY NANJUNDASWAMY (MD)
Entity type:Individual
Prefix:DR
First Name:BANATHALLY
Middle Name:NANJUNDASWAMY
Last Name:NANDISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:B.
Other - Middle Name:N
Other - Last Name:NANDISH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48376-0247
Mailing Address - Country:US
Mailing Address - Phone:248-449-4032
Mailing Address - Fax:734-737-0974
Practice Address - Street 1:20206 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1412
Practice Address - Country:US
Practice Address - Phone:248-476-4724
Practice Address - Fax:248-476-7091
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079475207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4858610Medicaid
MI0H26335OtherMEDICARE
MI0P31510OtherMEDICARE
MI4858610Medicaid
MIP31510001Medicare PIN