Provider Demographics
NPI:1447295324
Name:NANDALUR, MOHAN REDDI (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:REDDI
Last Name:NANDALUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98356
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-0365
Mailing Address - Country:US
Mailing Address - Phone:703-587-3913
Mailing Address - Fax:
Practice Address - Street 1:1215 N BEAVER STREET
Practice Address - Street 2:HEART & VASCULAR CENTER OF NORTHERN ARIZONA
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:703-587-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11895207RC0000X, 207RI0011X
MDD64943207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD155173Medicaid
ND15171Medicaid
MT000085424OtherMEDICARE GROUP NUMBER
MT000085424OtherMEDICARE GROUP NUMBER