Provider Demographics
NPI:1225178569
Name:CHANDRASEKHARA, MUTHAIAH (MD)
Entity Type:Individual
Prefix:MR
First Name:MUTHAIAH
Middle Name:
Last Name:CHANDRASEKHARA
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 1:15 FORTUNE RD W
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1625
Mailing Address - Country:US
Mailing Address - Phone:845-692-4454
Mailing Address - Fax:
Practice Address - Street 1:15 FORTUNE RD W
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1625
Practice Address - Country:US
Practice Address - Phone:845-692-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143024-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY09F732Medicare PIN