Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086X0206X | Surgical Oncologist | 165321 | NY |
NPI | 1275534711 |
---|---|
Provider Name | Nageswara R Mandava |
First Address | Rego Park, NY 11374-0008 |
Second Address | Flushing, NY 11355-2200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 17/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01124258 | (05) | NY |
E38238 | (02) |