Healthcare Provider Details

I. General information

NPI: 1063604270
Provider Name (Legal Business Name): MITCHELL CHANDLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 08/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 W 74TH ST APT 1F
NEW YORK NY
10023-2127
US

IV. Provider business mailing address

245 W 74TH ST APT 1F
NEW YORK NY
10023-2127
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number244765
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: