Healthcare Provider Details

I. General information

NPI: 1376925164
Provider Name (Legal Business Name): GEORGE CHANDRAN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 ENCINO PL NE SUITE 19
ALBUQUERQUE NM
87102-2611
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 Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number76-18
License Number StateNM

VIII. Authorized Official

Name: MR. EDWARD L LOBATO
Title or Position: MANAGER
Credential:
Phone: 505-884-1214