Provider Demographics
NPI:1710095526
Name:GEORGE, CHANDY V (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDY
Middle Name:V
Last Name:GEORGE
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 1:635 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3872
Mailing Address - Country:US
Mailing Address - Phone:414-344-5040
Mailing Address - Fax:414-344-7051
Practice Address - Street 1:635 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3872
Practice Address - Country:US
Practice Address - Phone:414-344-5040
Practice Address - Fax:414-344-7051
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30138300Medicaid
WI30138300Medicaid