Basic Information
Provider Information | |||||||||
NPI: | 1417060666 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHANDRA | ||||||||
FirstName: | SUNIL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4108 WATERMELON RD | ||||||||
Address2: |   | ||||||||
City: | NORTHPORT | ||||||||
State: | AL | ||||||||
PostalCode: | 354735130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2053669898 | ||||||||
FaxNumber: | 2053669896 | ||||||||
Practice Location | |||||||||
Address1: | 4108 WATERMELON RD | ||||||||
Address2: |   | ||||||||
City: | NORTHPORT | ||||||||
State: | AL | ||||||||
PostalCode: | 354735130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2053669898 | ||||||||
FaxNumber: | 2053669896 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2006 | ||||||||
LastUpdateDate: | 09/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20650 | AL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | 20650 | AL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208D00000X | 20650 | AL | N |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 529905210 | 05 | AL |   | MEDICAID |