Basic Information
Provider Information | |||||||||
NPI: | 1013955640 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NANDIPATI | ||||||||
FirstName: | SAILAJA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 SAINT PATRICKS DR | ||||||||
Address2: |   | ||||||||
City: | WALDORF | ||||||||
State: | MD | ||||||||
PostalCode: | 206034527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013737900 | ||||||||
FaxNumber: | 3013736900 | ||||||||
Practice Location | |||||||||
Address1: | 3500 OLD WASHINGTON RD | ||||||||
Address2: | SUITE 202 | ||||||||
City: | WALDORF | ||||||||
State: | MD | ||||||||
PostalCode: | 206023224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018432223 | ||||||||
FaxNumber: | 3018432355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2006 | ||||||||
LastUpdateDate: | 12/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | D0038037 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | G938 | 01 | DC | BLUE CROSS | OTHER | KEW2AR | 01 | MD | BLUE CROSS | OTHER | P00073690 | 01 | MD | RAILROAD MEDICARE | OTHER | 391192600 | 05 | MD |   | MEDICAID | 466904 | 01 | VA | BLUE CROSS | OTHER |