Provider Demographics
NPI:1114985819
Name:CHANDRASEKARAN, PRATHIBHA (MD)
Entity type:Individual
Prefix:
First Name:PRATHIBHA
Middle Name:
Last Name:CHANDRASEKARAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 SONOMA ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2519
Mailing Address - Country:US
Mailing Address - Phone:530-243-8667
Mailing Address - Fax:530-243-8742
Practice Address - Street 1:1825 SONOMA ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2519
Practice Address - Country:US
Practice Address - Phone:530-243-8667
Practice Address - Fax:530-243-8742
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55292207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4549259OtherAETNA
NJ8607001Medicaid
NJP00019213OtherRAILROAD MEDICARE
NJP2522732OtherOXFORD
NJ2K1650OtherHEALTHNET
NJP00019213OtherRAILROAD MEDICARE