Healthcare Provider Details

I. General information

NPI: 1740449396
Provider Name (Legal Business Name): CHANDRA SEKHAR YANGALASETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2008
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W WILSHIRE, SUITE A LA CASA FAMILY HEALTH CENTER/LOS NINOS PEDIATRICS
ROSWELL NM
88201
US

IV. Provider business mailing address

PO BOX 843
PORTALES NM
88130-0843
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-5956
  • Fax: 575-622-4059
Mailing address:
  • Phone: 575-356-6695
  • Fax: 575-356-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11251
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2011-0534
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: