Provider Demographics
NPI:1154585990
Name:VEDAMANIKAM, CHANDRAN (MD)
Entity type:Individual
Prefix:
First Name:CHANDRAN
Middle Name:
Last Name:VEDAMANIKAM
Suffix:
Gender:
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:PO BOX 2707
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-2707
Mailing Address - Country:US
Mailing Address - Phone:575-526-3625
Mailing Address - Fax:575-526-7112
Practice Address - Street 1:909 N DATE ST STE B
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-1747
Practice Address - Country:US
Practice Address - Phone:575-636-2388
Practice Address - Fax:575-680-2591
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2008-0187207Q00000X
NMMD2012-0121207Q00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61507334Medicaid