Healthcare Provider Details

I. General information

NPI: 1942367883
Provider Name (Legal Business Name): CHIDAMBARANATHAN CHANDRASEKARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 PATCHOGUE YAPHANK RD
EAST PATCHOGUE NY
11772-4861
US

IV. Provider business mailing address

286 PATCHOGUE YAPHANK RD
EAST PATCHOGUE NY
11772-4861
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-7862
  • Fax: 631-475-1969
Mailing address:
  • Phone: 631-289-7862
  • Fax: 631-475-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number164610
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: