Provider Demographics
NPI:1841297892
Name:CHANDRAMOHAN, AJITHA (MD)
Entity type:Individual
Prefix:
First Name:AJITHA
Middle Name:
Last Name:CHANDRAMOHAN
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 1:1743 SOUTHVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-9324
Mailing Address - Country:US
Mailing Address - Phone:936-591-8888
Mailing Address - Fax:936-591-8884
Practice Address - Street 1:1743 SOUTHVIEW CIR
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-9324
Practice Address - Country:US
Practice Address - Phone:936-591-8888
Practice Address - Fax:936-591-8884
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156997201Medicaid
G85898Medicare UPIN
TX156997201Medicaid