Healthcare Provider Details

I. General information

NPI: 1104824531
Provider Name (Legal Business Name): SUDHA CHANDRASEKHAR M.D., M.P.H., IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2005
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S DOBSON RD SUITE 1
CHANDLER AZ
85224-6183
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 480-963-6668
  • Fax: 480-963-6669
Mailing address:
  • Phone: 602-933-1814
  • Fax: 602-933-1820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29340
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number29340
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: