Provider Demographics
NPI:1225085970
Name:CHIDAMBARAM, SHOBHA I (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBHA
Middle Name:I
Last Name:CHIDAMBARAM
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 1:1406 GREENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1604
Mailing Address - Country:US
Mailing Address - Phone:703-461-3785
Mailing Address - Fax:
Practice Address - Street 1:6196 OXON HILL RD
Practice Address - Street 2:SUITE 220
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3100
Practice Address - Country:US
Practice Address - Phone:301-839-1590
Practice Address - Fax:301-839-2690
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00297442084N0400X
DCMD121722084N0400X
VA01010327562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101032756OtherVIRGINIA LICENCSE #
MDD0029744OtherMARYLAND LICENSE #
DCMD12172OtherDC LICENSE #
0898534OtherAETNA
MD2308OtherBX/BS OF MARYLAND
2506OtherBLUECROSS BS OF DC
0898534OtherAETNA
B94742Medicare UPIN