Provider Demographics
NPI:1063641546
Name:CHANDRAMOULI, SUSHMA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHMA
Middle Name:
Last Name:CHANDRAMOULI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E POTTAWATAMIE ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-2018
Mailing Address - Country:US
Mailing Address - Phone:573-201-8348
Mailing Address - Fax:
Practice Address - Street 1:500 E POTTAWATAMIE ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-2018
Practice Address - Country:US
Practice Address - Phone:573-201-8348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090092502084P0800X
MI43011020442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry