Provider Demographics
NPI:1649256322
Name:CHANDRA, JEEVARATNAM S (MD)
Entity type:Individual
Prefix:
First Name:JEEVARATNAM
Middle Name:S
Last Name:CHANDRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEEVARATNAM
Other - Middle Name:S
Other - Last Name:CHANDRASEKAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:310 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3133
Mailing Address - Country:US
Mailing Address - Phone:936-632-8787
Mailing Address - Fax:936-632-8832
Practice Address - Street 1:310 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3133
Practice Address - Country:US
Practice Address - Phone:936-632-8787
Practice Address - Fax:936-632-8832
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4097207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128236002Medicaid
TXTXB125699Medicare PIN
TX82A542Medicare PIN
TXC14366Medicare UPIN