Healthcare Provider Details

I. General information

NPI: 1154585990
Provider Name (Legal Business Name): CHANDRAN VEDAMANIKAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 EUBANK BLVD NE STE H
ALBUQUERQUE NM
87111-3559
US

IV. Provider business mailing address

700 S TELSHOR BLVD STE 1460
LAS CRUCES NM
88011-8607
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-3397
  • Fax: 505-323-7980
Mailing address:
  • Phone: 575-567-7774
  • Fax: 575-205-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRS2008-0187
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberMD2012-0121
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2012-0121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: