Provider Demographics
NPI:1942367883
Name:CHANDRASEKARAN, CHIDAMBARANATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHIDAMBARANATHAN
Middle Name:
Last Name:CHANDRASEKARAN
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 1:286 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4861
Mailing Address - Country:US
Mailing Address - Phone:631-289-7862
Mailing Address - Fax:631-475-1969
Practice Address - Street 1:286 PATCHOGUE YAPHANK RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4861
Practice Address - Country:US
Practice Address - Phone:631-289-7862
Practice Address - Fax:631-475-1969
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164610207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA64051Medicare UPIN
NY73D481Medicare ID - Type Unspecified