Provider Demographics
NPI:1306878434
Name:MOULI, S. CHANDRA (MD)
Entity type:Individual
Prefix:DR
First Name:S. CHANDRA
Middle Name:
Last Name:MOULI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 DEERFIELD RD
Mailing Address - Street 2:SUITE 100 PMB 418
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3241
Mailing Address - Country:US
Mailing Address - Phone:708-667-4333
Mailing Address - Fax:
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-681-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0487762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-048776Medicaid
IL212187Medicare PIN
IL036-048776Medicaid
ILC38037Medicare UPIN
ILK16948Medicare PIN