Healthcare Provider Details

I. General information

NPI: 1679752075
Provider Name (Legal Business Name): B. V. CHANDRAMOULI, M..D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 EAST ST SUITE 100
REDDING CA
96001-1153
US

IV. Provider business mailing address

1555 EAST ST SUITE 100
REDDING CA
96001-1153
US

V. Phone/Fax

Practice location:
  • Phone: 530-244-4471
  • Fax: 530-244-1407
Mailing address:
  • Phone: 530-244-4471
  • Fax: 530-244-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number00A521990
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number00A521990
License Number StateCA

VIII. Authorized Official

Name: B V CHANDRAMOULI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 530-244-4471