Provider Demographics
NPI:1932376472
Name:NANJAIAH, SUDHARANI BANGALORE (MD)
Entity Type:Individual
Prefix:MS
First Name:SUDHARANI
Middle Name:BANGALORE
Last Name:NANJAIAH
Suffix:
Gender:F
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:038-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:115 N SUMTER ST STE 400
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-774-7425
Practice Address - Fax:803-774-9426
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434991207Q00000X
390200000X
SC81670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025377070001Medicaid
SC816709Medicaid