Healthcare Provider Details

I. General information

NPI: 1669472601
Provider Name (Legal Business Name): RAJAGOPAL R NANDYAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RAJA R NANDYAL MD

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

O.U. MEDICAL CENTER, 1200 EVERETT DR, 7TH FLOOR, NORTH PAVILION
OKLAHOMA CITY OK
73104
US

IV. Provider business mailing address

2617 LILLEHAMMER DR
EDMOND OK
73034-9157
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5215
  • Fax: 405-271-1236
Mailing address:
  • Phone: 405-285-2820
  • Fax: 405-271-1236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number11599
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number24228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: