Healthcare Provider Details

I. General information

NPI: 1093888604
Provider Name (Legal Business Name): GEORGE CHANDRAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 ENCINO PL NE STE 19
ALBUQUERQUE NM
87102-2653
US

IV. Provider business mailing address

PO BOX 35310
ALBUQUERQUE NM
87176-5310
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-1744
  • Fax: 505-247-0797
Mailing address:
  • Phone: 505-247-1744
  • Fax: 505-247-0797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number76-18
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: