Provider Demographics
NPI:1720350465
Name:CHANDRADAS, SAJIV (MD)
Entity Type:Individual
Prefix:
First Name:SAJIV
Middle Name:
Last Name:CHANDRADAS
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 1:1200 N STATE ST
Mailing Address - Street 2:CT-A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-226-7556
Mailing Address - Fax:323-226-2657
Practice Address - Street 1:4060 4TH AVE STE 240
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2120
Practice Address - Country:US
Practice Address - Phone:619-291-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122474207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113776OtherSID #113776