Provider Demographics
NPI:1669431110
Name:NANDAKUMAR, THAMBIRAJAH (MD)
Entity type:Individual
Prefix:
First Name:THAMBIRAJAH
Middle Name:
Last Name:NANDAKUMAR
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 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7887
Mailing Address - Fax:631-454-4161
Practice Address - Street 1:13420 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2619
Practice Address - Country:US
Practice Address - Phone:718-206-6742
Practice Address - Fax:718-206-6905
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2135442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02048759Medicaid
H06998Medicare UPIN
NY0105KSMedicare PIN