Provider Demographics
NPI:1497742092
Name:CHANDRA, SUDHISH (MD)
Entity Type:Individual
Prefix:
First Name:SUDHISH
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:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0800
Mailing Address - Country:US
Mailing Address - Phone:219-864-2107
Mailing Address - Fax:219-864-2649
Practice Address - Street 1:5454 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1931
Practice Address - Country:US
Practice Address - Phone:219-933-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059766A2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0090000854OtherBCBS GROUP NUMBER
IN200409950Medicaid
H95746Medicare UPIN
IN200409950Medicaid