Healthcare Provider Details

I. General information

NPI: 1710963947
Provider Name (Legal Business Name): JALAJ CHANDNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

5700 DARROW RD SUITE 106
HUDSON OH
44236-5021
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-1939
  • Fax: 740-374-1693
Mailing address:
  • Phone: 330-656-5911
  • Fax: 330-656-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20670
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.070350
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: