Healthcare Provider Details

I. General information

NPI: 1700451077
Provider Name (Legal Business Name): NITYA TANGADA RAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4091
  • Fax: 336-716-7994
Mailing address:
  • Phone: 336-716-4091
  • Fax: 336-716-7994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2025-00758
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: