Healthcare Provider Details

I. General information

NPI: 1134412901
Provider Name (Legal Business Name): CHANDRA MOULI CHERUKURI M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 NICOLLET AVE
MINNEAPOLIS MN
55408-4708
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-6963
  • Fax: 612-545-9049
Mailing address:
  • Phone: 763-873-3000
  • Fax: 612-873-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57381
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number57381
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number57381
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: