Healthcare Provider Details

I. General information

NPI: 1427484492
Provider Name (Legal Business Name): DB CHANDORA MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2560
US

IV. Provider business mailing address

565 LAKE FRONT DR
LILBURN GA
30047-7317
US

V. Phone/Fax

Practice location:
  • Phone: 404-550-3248
  • Fax: 770-892-5259
Mailing address:
  • Phone: 404-550-3248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number25954
License Number StateGA

VIII. Authorized Official

Name: DR. DEEN B CHANDORA
Title or Position: OWNER
Credential: MD
Phone: 404-550-3248