Provider Demographics
NPI:1689170516
Name:TALLAM, NITIN PRAVEEN (MD)
Entity type:Individual
Prefix:
First Name:NITIN
Middle Name:PRAVEEN
Last Name:TALLAM
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 1:200 MUIR RD
Mailing Address - Street 2:PHYSICAL MEDICINE & REHABILITATION
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4614
Mailing Address - Country:US
Mailing Address - Phone:925-372-1000
Mailing Address - Fax:
Practice Address - Street 1:200 MUIR RD
Practice Address - Street 2:PHYSICAL MEDICINE & REHABILITATION
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553
Practice Address - Country:US
Practice Address - Phone:925-372-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1759722081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine