Provider Demographics
NPI:1982772901
Name:CHANDA-KIM, MOUSUMI (MD)
Entity Type:Individual
Prefix:
First Name:MOUSUMI
Middle Name:
Last Name:CHANDA-KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOUSUMI
Other - Middle Name:
Other - Last Name:CHANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 W WILLIAM CANNON DR STE 303
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5289
Mailing Address - Country:US
Mailing Address - Phone:512-444-4001
Mailing Address - Fax:512-582-0167
Practice Address - Street 1:5103 KYLE CENTER DR STE 104
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6164
Practice Address - Country:US
Practice Address - Phone:512-504-0855
Practice Address - Fax:512-504-0856
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CN818OtherBCBS
TX096822405Medicaid
TX096822404Medicaid
TXH03524Medicare UPIN
TXTXB117863Medicare PIN
TX096822404Medicaid