MEDICARE: MALLIKARJUNA NANDYALA MD PA

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	ME0070271	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	ME0070271	OTHER	FL	MEDICAL STATE LICENSE

General Provider Information

NPI Number	:	1427383512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALLIKARJUNA NANDYALA MD PA

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	:	8313 W HILLSBOROUGH AVE STE 300
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-3819
Country	:	US
Telephone Number	:	813-884-0222
Fax Number	:	813-884-0080

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MALLIKARJUNA NANDYALA
Credential	:	M.D.
Telephone Number	:	813-884-0222

Provider Enumeration Date	:	10/07/2009
Last Update Date	:	01/30/2013

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