Provider Demographics
NPI:1083658827
Name:MUDJIANTO CHANDRA, M.D., INC.
Entity Type:Organization
Organization Name:MUDJIANTO CHANDRA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUDJIANTO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-708-1004
Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:SUITE 607
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2804
Mailing Address - Country:US
Mailing Address - Phone:818-708-1004
Mailing Address - Fax:818-342-2141
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:SUITE 607
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2804
Practice Address - Country:US
Practice Address - Phone:818-708-1004
Practice Address - Fax:818-342-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52198208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A521980OtherBLUE SHIELD
P92709600OtherOXFORD INSURANCE
CA00A521980Medicaid
A52198OtherPRIVATE INSURANCE PIN
00A521980OtherBLUE SHIELD
A52198OtherPRIVATE INSURANCE PIN