Basic Information
| Provider Information | |||||||||
| NPI: | 1093928913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAZUMDER | ||||||||
| FirstName: | CHANDAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4214 ANDREWS HWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797034817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326866605 | ||||||||
| FaxNumber: | 4326822284 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 W WALL ST STE C | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797016568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4322212500 | ||||||||
| FaxNumber: | 4326871914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME 98432 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | P3771 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 279640600 | 05 | FL | MEDICAID | 305512101 | 05 | TX | MEDICAID |