Healthcare Provider Details

I. General information

NPI: 1275534711
Provider Name (Legal Business Name): NAGESWARA R MANDAVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14601 45TH AVE SUITE 405
FLUSHING NY
11355-2200
US

IV. Provider business mailing address

PO BOX 740008
REGO PARK NY
11374-0008
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-5202
  • Fax: 718-670-5312
Mailing address:
  • Phone: 718-670-5202
  • Fax: 718-670-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number165321
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: