Provider Demographics
NPI:1467446013
Name:CHANDRASOMA, PARAKRAMA T (MD)
Entity Type:Individual
Prefix:
First Name:PARAKRAMA
Middle Name:T
Last Name:CHANDRASOMA
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 1:405 LINDA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-1237
Mailing Address - Country:US
Mailing Address - Phone:323-226-4600
Mailing Address - Fax:323-226-5927
Practice Address - Street 1:405 LINDA VISTA AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1237
Practice Address - Country:US
Practice Address - Phone:323-226-4600
Practice Address - Fax:323-226-5927
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34284207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A342840Medicaid
CAA27439Medicare UPIN
CA00A342840Medicaid