Healthcare Provider Details

I. General information

NPI: 1235295213
Provider Name (Legal Business Name): CHANDRA KUNCHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 5TH AVE
BROOKLYN NY
11209-2704
US

IV. Provider business mailing address

7404 5TH AVE
BROOKLYN NY
11209-2704
US

V. Phone/Fax

Practice location:
  • Phone: 718-439-5111
  • Fax: 718-439-6108
Mailing address:
  • Phone: 718-439-5111
  • Fax: 718-439-6108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number154059
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: