Healthcare Provider Details

I. General information

NPI: 1366484123
Provider Name (Legal Business Name): BIRUR G CHANDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 BRIDGEPORT AVE
MILFORD CT
06460-4633
US

IV. Provider business mailing address

2044 BRIDGEPORT AVE
MILFORD CT
06460-4633
US

V. Phone/Fax

Practice location:
  • Phone: 203-878-8300
  • Fax: 203-878-0422
Mailing address:
  • Phone: 203-878-8300
  • Fax: 203-878-0422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number017218
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: