Healthcare Provider Details

I. General information

NPI: 1710913082
Provider Name (Legal Business Name): NANDAKISHORE DUKKIPATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MEDICAL DR
BLYTHEVILLE AR
72315-1425
US

IV. Provider business mailing address

608 S ESTATE DR
BLYTHEVILLE AR
72315-8005
US

V. Phone/Fax

Practice location:
  • Phone: 870-762-6725
  • Fax:
Mailing address:
  • Phone: 870-776-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-4520
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: