1831207570 NPI number — NAGENDRANATH DHANYAMRAJU M.D.

Table of content: NAGENDRANATH DHANYAMRAJU M.D. (NPI 1831207570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831207570 NPI number — NAGENDRANATH DHANYAMRAJU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DHANYAMRAJU
Provider First Name:
NAGENDRANATH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831207570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3998 FAIR RIDGE DRIVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-295-9360
Provider Business Mailing Address Fax Number:
703-766-9725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 MASSACHUSETTS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12180-1628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-268-5554
Provider Business Practice Location Address Fax Number:
518-268-5396
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  204569 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05010 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5399982 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000490204001 . This is a "BSNENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7459616 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01749504 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10023510 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 204569-8AN . This is a "WC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 66A641 . This is a "EMPIRE BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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