Provider Demographics
NPI:1518969104
Name:CHANDRAN, PREM KG (MD)
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:KG
Last Name:CHANDRAN
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 1:411 LAUREL ST STE 2350
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-3026
Mailing Address - Country:US
Mailing Address - Phone:515-280-4700
Mailing Address - Fax:515-280-4701
Practice Address - Street 1:411 LAUREL ST, SUITE 2350
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314
Practice Address - Country:US
Practice Address - Phone:515-280-4700
Practice Address - Fax:515-280-4701
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24158207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1518969104OtherWELLMARK BCBS
IAP00329636OtherRAILROAD MEDICARE
IA13649OtherWELLMARK BCBS
IA1518969104Medicaid
IA1518969104Medicaid
IAI-17645Medicare PIN
A54923Medicare UPIN
IA13649OtherWELLMARK BCBS