Healthcare Provider Details

I. General information

NPI: 1538117015
Provider Name (Legal Business Name): CHANDRESH VITHAL VIRADIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JIM MASON CT
WARNER ROBINS GA
31088-8965
US

IV. Provider business mailing address

100 JIM MASON CT
WARNER ROBINS GA
31088-8965
US

V. Phone/Fax

Practice location:
  • Phone: 478-971-4001
  • Fax: 478-971-4004
Mailing address:
  • Phone: 478-971-4001
  • Fax: 478-971-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number053050
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number053050
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number053050
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: