Provider Demographics
NPI:1164847042
Name:CHANDULA, SIVANANDA
Entity Type:Individual
Prefix:
First Name:SIVANANDA
Middle Name:
Last Name:CHANDULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-4504
Mailing Address - Country:US
Mailing Address - Phone:732-762-9690
Mailing Address - Fax:
Practice Address - Street 1:1743 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4614
Practice Address - Country:US
Practice Address - Phone:212-234-7959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist