Healthcare Provider Details

I. General information

NPI: 1154400547
Provider Name (Legal Business Name): CHANDANA PRABHUDEV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 W MCINTOSH RD
GRIFFIN GA
30223-1717
US

IV. Provider business mailing address

1661 W MCINTOSH RD
GRIFFIN GA
30223-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-233-4668
  • Fax: 678-666-5131
Mailing address:
  • Phone: 770-233-4668
  • Fax: 678-666-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number055272
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: