Basic Information
| Provider Information | |||||||||
| NPI: | 1639114077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANDRA | ||||||||
| FirstName: | SAMIR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 KIMBALL AVE | ||||||||
| Address2: | LL14 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192721590 | ||||||||
| FaxNumber: | 3192721535 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SAINT FRANCIS DR | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
| FaxNumber: | 3192725445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 34779 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 34779 | IA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 0269399 | 05 | IA | MEDICAID |