Healthcare Provider Details

I. General information

NPI: 1396242954
Provider Name (Legal Business Name): PRAVEEN NANDAMURU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY # 512-17
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

1 CHILDRENS WAY # 653
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1893
  • Fax: 501-364-2865
Mailing address:
  • Phone: 501-364-1100
  • Fax: 501-364-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021022245
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-16579
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberE-16579
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: