MEDICARE: DR. GANGADARSHNI CHANDRAMOHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0210X	Pediatric Nephrology Physician	A51443	CA

General Provider Information

NPI Number	:	1750351300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GANGADARSHNI CHANDRAMOHAN M.D.

Provider Business Mailing Address
First Line	:	2320 CUMBERLAND RD
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2105
Country	:	US
Telephone Number	:	626-583-9161
Fax Number	:	626-432-4535

Provider Business Practice Location Address
First Line	:	12021 WILMINGTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90059-3019
Country	:	US
Telephone Number	:	310-668-4653
Fax Number	:	310-668-8715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/08/2007

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