Basic Information
| Provider Information | |||||||||
| NPI: | 1912994971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VRINDAVANAM | ||||||||
| FirstName: | NANDAGOPAL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 PARK ST N STE 1017 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337092236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273446570 | ||||||||
| FaxNumber: | 7273844388 | ||||||||
| Practice Location | |||||||||
| Address1: | 6555 CORTEZ RD W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342102608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273446569 | ||||||||
| FaxNumber: | 7273844388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | ME126543 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | Q8181 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | ME126543 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 7FNM3 | 01 | FL | BCBS FL | OTHER | LI140 | 01 | FL | MEDICARE | OTHER | 103361400 | 05 | FL | MEDICAID | 3590879-01 | 05 | TX | MEDICAID | LI139 | 01 | FL | MEDICARE | OTHER | 7FNM3 | 01 | FL | BCBS | OTHER |