Provider Demographics
NPI:1841366127
Name:CHANDRA, MANJU (MD)
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:
Last Name:CHANDRA
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 1:173 MINEOLA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2529
Mailing Address - Country:US
Mailing Address - Phone:516-663-9494
Mailing Address - Fax:
Practice Address - Street 1:173 MINEOLA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2529
Practice Address - Country:US
Practice Address - Phone:516-663-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1190562080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00630828Medicaid
NY00630828Medicaid
NY307371Medicare PIN