Healthcare Provider Details

I. General information

NPI: 1265489389
Provider Name (Legal Business Name): CHANDER S BHATIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E ROOSEVELT AVE EMERGENCY DEPARTMENT
GRANTS NM
87020-2118
US

IV. Provider business mailing address

3200 BLUE HILL AVE
GALLUP NM
87301-6933
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-5260
  • Fax:
Mailing address:
  • Phone: 505-726-8261
  • Fax: 505-726-8261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number97-191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: