Healthcare Provider Details

I. General information

NPI: 1396794780
Provider Name (Legal Business Name): NAKUL CHANDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 PAVILION AVE
LONG BRANCH NJ
07740-6415
US

IV. Provider business mailing address

137 PAVILION AVE
LONG BRANCH NJ
07740-6415
US

V. Phone/Fax

Practice location:
  • Phone: 732-870-1611
  • Fax:
Mailing address:
  • Phone: 732-870-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number25096
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: