Provider Demographics
NPI:1548353022
Name:NALLA, SUNDARA C (MD)
Entity type:Individual
Prefix:
First Name:SUNDARA
Middle Name:C
Last Name:NALLA
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 1:229 SYLVAN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-2421
Mailing Address - Country:US
Mailing Address - Phone:507-749-0111
Mailing Address - Fax:
Practice Address - Street 1:229 SYLVAN DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-2421
Practice Address - Country:US
Practice Address - Phone:507-749-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM115527OtherUCARE
MN0D930NAOtherBCBS MPIN
MN080120227OtherRR MEDICARE
MN950797300Medicaid
IA1967802Medicaid
MN080120227OtherRR MEDICARE
MN0D930NAOtherBCBS MPIN