Healthcare Provider Details

I. General information

NPI: 1386835601
Provider Name (Legal Business Name): NAGA LAKSHMANA PRASAD NIDADAVOLU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NAGALAKSHMANA PRASAD NIDADAVOLU M.D

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1400
US

IV. Provider business mailing address

4745 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1400
US

V. Phone/Fax

Practice location:
  • Phone: 407-818-1664
  • Fax: 407-818-1654
Mailing address:
  • Phone: 407-818-1664
  • Fax: 407-818-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberME109423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: