Basic Information
| Provider Information | |||||||||
| NPI: | 1649265828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANDLER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | AVILLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2608973556 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BAUM STREET | ||||||||
| Address2: | |||||||||
| City: | AVILLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467100170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2608973556 | ||||||||
| FaxNumber: | 2608973650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 09/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01022980 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000559371 | 01 | IN | ANTHEM | OTHER | 000000570562 | 01 | IN | ANTHEM | OTHER | 100190780A | 05 | IN | MEDICAID | P00664344 | 01 | IN | MEDICARE RAILROAD | OTHER |