Provider Demographics
NPI:1801928577
Name:DANDAMUDI, SHYAM S (MD)
Entity type:Individual
Prefix:MR
First Name:SHYAM
Middle Name:S
Last Name:DANDAMUDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 S TRUMBULL
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-4217
Mailing Address - Country:US
Mailing Address - Phone:989-893-5541
Mailing Address - Fax:989-893-5543
Practice Address - Street 1:714 S TRUMBULL
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-4217
Practice Address - Country:US
Practice Address - Phone:989-893-5541
Practice Address - Fax:989-893-5543
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101398348Medicaid
MI101398348Medicaid
MI0Z96016002Medicare ID - Type Unspecified