Provider Demographics
NPI:1215977129
Name:CHANDLER, CONNIE A (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:A
Last Name:CHANDLER
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:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36361-0863
Mailing Address - Country:US
Mailing Address - Phone:334-443-1211
Mailing Address - Fax:334-443-0131
Practice Address - Street 1:145 KATHERINE AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1976
Practice Address - Country:US
Practice Address - Phone:334-774-5116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-78140OtherBLUE CROSS AND BLUE SHIELD
AL185389Medicaid
AL1123Medicare ID - Type Unspecified