Provider Demographics
NPI:1912994971
Name:VRINDAVANAM, NANDAGOPAL S (MD)
Entity Type:Individual
Prefix:DR
First Name:NANDAGOPAL
Middle Name:S
Last Name:VRINDAVANAM
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 1:5000 PARK ST N STE 1017
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2236
Mailing Address - Country:US
Mailing Address - Phone:727-344-6570
Mailing Address - Fax:727-384-4388
Practice Address - Street 1:6555 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-2608
Practice Address - Country:US
Practice Address - Phone:727-344-6569
Practice Address - Fax:727-384-4388
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126543207RH0003X, 207RX0202X
TXQ8181207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7FNM3OtherBCBS FL
FLLI140OtherMEDICARE
FL103361400Medicaid
TX3590879-01Medicaid
FLLI139OtherMEDICARE
FL7FNM3OtherBCBS