Provider Demographics
NPI:1689743064
Name:CHANDY, MAMMEN GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MAMMEN
Middle Name:GEORGE
Last Name:CHANDY
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 1:2721 OLIVE HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6115
Mailing Address - Country:US
Mailing Address - Phone:530-534-0750
Mailing Address - Fax:
Practice Address - Street 1:2721 OLIVE HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6115
Practice Address - Country:US
Practice Address - Phone:530-534-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A353960Medicaid
CAE69367Medicare UPIN
CA00A353960Medicare ID - Type Unspecified