Provider Demographics
NPI:1093928913
Name:MAZUMDER, CHANDAN (MD)
Entity Type:Individual
Prefix:
First Name:CHANDAN
Middle Name:
Last Name:MAZUMDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 ANDREWS HWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4817
Mailing Address - Country:US
Mailing Address - Phone:432-686-6605
Mailing Address - Fax:432-682-2284
Practice Address - Street 1:1900 W WALL ST STE C
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6568
Practice Address - Country:US
Practice Address - Phone:432-221-2500
Practice Address - Fax:432-687-1914
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 98432208000000X
TXP3771208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279640600Medicaid
TX305512101Medicaid