Provider Demographics
NPI:1568453454
Name:CHANDRAMOHAN, SHANMUGANATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:SHANMUGANATHAN
Middle Name:
Last Name:CHANDRAMOHAN
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 1:16177 KAMANA ROAD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1377
Mailing Address - Country:US
Mailing Address - Phone:760-946-0618
Mailing Address - Fax:760-946-0584
Practice Address - Street 1:16177 KAMANA ROAD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1377
Practice Address - Country:US
Practice Address - Phone:760-946-0618
Practice Address - Fax:760-946-0584
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52661174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG34583Medicare UPIN