Provider Demographics
NPI:1073667317
Name:CHANDRASEKARAN, VENKATAPERUMAL R (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATAPERUMAL
Middle Name:R
Last Name:CHANDRASEKARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:V. RAJA
Other - Middle Name:
Other - Last Name:CHANDRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1006 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3900
Mailing Address - Country:US
Mailing Address - Phone:970-224-1596
Mailing Address - Fax:970-530-1919
Practice Address - Street 1:1006 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3900
Practice Address - Country:US
Practice Address - Phone:970-224-1596
Practice Address - Fax:970-530-1919
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38385208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62086022Medicaid
CO275345YMMYMedicare PIN
WY106489400Medicaid
WY00072001OtherBCBS
WY760011087OtherRAILROAD MEDICARE