Basic Information
| Provider Information | |||||||||
| NPI: | 1932175502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PANDYA & NIME MD PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PATHOLOGY AND MEDICAL LABORATORY DIAGNOSTIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1943 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772619061 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216362211 | ||||||||
| FaxNumber: | 3216337085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOUIE | ||||||||
| AuthorizedOfficialFirstName: | SHONDELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3216362211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 055386700 | 05 | FL | MEDICAID | 055386703 | 05 | FL | MEDICAID |