Provider Demographics
NPI:1396115630
Name:MENDU, DAMODARA RAO (PHD)
Entity type:Individual
Prefix:
First Name:DAMODARA
Middle Name:RAO
Last Name:MENDU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-2714
Mailing Address - Country:US
Mailing Address - Phone:954-925-6533
Mailing Address - Fax:
Practice Address - Street 1:6555 NW 9TH AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2067
Practice Address - Country:US
Practice Address - Phone:954-925-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDI46724247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDI46724OtherFLORIDA LICENSE