Healthcare Provider Details

I. General information

NPI: 1023201241
Provider Name (Legal Business Name): VIJAYALAKSHMI NANDIMANDALAM, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 E 6TH ST SUITE 100
BONHAM TX
75418-4095
US

IV. Provider business mailing address

1211 E 6TH ST SUITE 100
BONHAM TX
75418-4095
US

V. Phone/Fax

Practice location:
  • Phone: 903-640-4700
  • Fax: 903-640-1975
Mailing address:
  • Phone: 903-640-4700
  • Fax: 903-640-1975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM5849
License Number StateTX

VIII. Authorized Official

Name: BECKY BLEVINS
Title or Position: OFFICE MANAGER
Credential:
Phone: 903-640-4700