Provider Demographics
NPI:1790937332
Name:CHANDRASENA, AMANTHI (MD)
Entity Type:Individual
Prefix:
First Name:AMANTHI
Middle Name:
Last Name:CHANDRASENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 OAK PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3408
Mailing Address - Country:US
Mailing Address - Phone:805-481-2205
Mailing Address - Fax:805-481-2206
Practice Address - Street 1:901 OAK PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449
Practice Address - Country:US
Practice Address - Phone:805-481-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0-641-796-8OtherECFMG NUMBER
CA0-641-796-8OtherECFMG NUMBER