Healthcare Provider Details

I. General information

NPI: 1124329016
Provider Name (Legal Business Name): VANI KUDLUR CHANDRAPPA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 GOODMAN RD
OLIVE BRANCH MS
38654-7902
US

IV. Provider business mailing address

9871 GARDEN PL
GERMANTOWN TN
38139-6934
US

V. Phone/Fax

Practice location:
  • Phone: 662-893-9877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49385
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: