Provider Demographics
NPI:1851829212
Name:CHADDHA, KRISHAN SHIVAM (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISHAN
Middle Name:SHIVAM
Last Name:CHADDHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-340-3911
Mailing Address - Fax:760-773-1440
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-340-3911
Practice Address - Fax:760-773-1440
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A16971207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty