Healthcare Provider Details

I. General information

NPI: 1316906845
Provider Name (Legal Business Name): SUDHA M CHADALAWADA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 UNIVERSITY AVE W MAIL STOP 13901B SUITE 160
SAINT PAUL MN
55114-1270
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3500
  • Fax: 651-254-3699
Mailing address:
  • Phone: 952-883-5463
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45683
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: