Basic Information
| Provider Information | |||||||||
| NPI: | 1093236580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KODAVANTI | ||||||||
| FirstName: | CHANDRA KUMAR MALLIC | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC 10-5550 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724751 | ||||||||
| FaxNumber: | 5052728700 | ||||||||
| Practice Location | |||||||||
| Address1: | MSC 10-5550 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724751 | ||||||||
| FaxNumber: | 5052728700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10060414 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | RS2020-0463 | NM | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.