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: 04/07/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N DATE ST STE B
TRUTH OR CONSEQUENCES NM
87901-1747
US

IV. Provider business mailing address

PO BOX 2707
LAS CRUCES NM
88004-2707
US

V. Phone/Fax

Practice location:
  • Phone: 575-636-2388
  • Fax: 575-680-2591
Mailing address:
  • Phone: 575-526-3625
  • Fax: 575-526-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: