Provider Demographics
NPI:1225152515
Name:CHANDRA, MUDJIANTO (MD)
Entity Type:Individual
Prefix:DR
First Name:MUDJIANTO
Middle Name:
Last Name:CHANDRA
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 1:18370 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:818-709-8161
Mailing Address - Fax:818-709-8160
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:818-709-8161
Practice Address - Fax:818-709-8160
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52198208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A521980OtherBLUE SHIELD
A52198OtherOTHER
A52198OtherTRICARE
P92709600OtherOXFORD
CAA52198OtherBLUE CROSS
CA00A521980Medicaid
P92709600OtherOXFORD
A52198OtherTRICARE