Basic Information
| Provider Information | |||||||||
| NPI: | 1528002342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NANDIPATI | ||||||||
| FirstName: | S | ||||||||
| MiddleName: | KRISHNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 OLD WASHINGTON RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018432222 | ||||||||
| FaxNumber: | 3018432355 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 OLD WASHINGTON RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018432222 | ||||||||
| FaxNumber: | 3018432355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 38160 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 147647 | 01 | VA | BLUE CROSS | OTHER | G939 | 01 | DC | BLUE CROSS | OTHER | 528031100 | 05 | MD | MEDICAID | KEW3NE | 01 | MD | BLUE CROSS | OTHER |