MEDICARE: DR. MALLIKARJUNA NANDYALA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME70271	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110244550	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2509053	OTHER	FL	AETNA
3	113934	OTHER	FL	AMERIGROUP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	243309	OTHER	FL	AVMED
6	31236	OTHER	FL	BLUE CROSS BLUE SHIELD
7	ME0070271	OTHER	FL	MEDICAL STATE LICENSE
8	2513301	OTHER	FL	GHI
9	139275BJ	OTHER	FL	PREFERRED CARE
10	169930	OTHER	FL	STAYWELL
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023081676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALLIKARJUNA NANDYALA M.D.

Provider Business Mailing Address
First Line	:	14749 WATERCHASE BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-3318
Country	:	US
Telephone Number	:	813-884-0222
Fax Number	:	813-884-0080

Provider Business Practice Location Address
First Line	:	13642 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33635-9638
Country	:	US
Telephone Number	:	813-884-0222
Fax Number	:	813-884-0080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	10/17/2013

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