Healthcare Provider Details

I. General information

NPI: 1922075464
Provider Name (Legal Business Name): VIJAYALAKSHMI NANDIMANDALAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 12/28/2010
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:
Title or Position:
Credential:
Phone: