Healthcare Provider Details

I. General information

NPI: 1750351300
Provider Name (Legal Business Name): GANGADARSHNI CHANDRAMOHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

2320 CUMBERLAND RD
SAN MARINO CA
91108-2105
US

V. Phone/Fax

Practice location:
  • Phone: 310-668-4653
  • Fax: 310-668-8715
Mailing address:
  • Phone: 626-583-9161
  • Fax: 626-432-4535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberA51443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: