Healthcare Provider Details

I. General information

NPI: 1689808875
Provider Name (Legal Business Name): KEVIN LENELLE CHANDLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 WASHINGTON ST
WATERTOWN NY
13601-4099
US

IV. Provider business mailing address

830 WASHINGTON ST
WATERTOWN NY
13601-4099
US

V. Phone/Fax

Practice location:
  • Phone: 803-318-3004
  • Fax:
Mailing address:
  • Phone: 803-318-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125054165
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number274532
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: