Provider Demographics
NPI:1699749077
Name:MUDALIAR, CHANDRAMOHAN G (MD)
Entity type:Individual
Prefix:
First Name:CHANDRAMOHAN
Middle Name:G
Last Name:MUDALIAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHANDRA
Other - Middle Name:G
Other - Last Name:MUDALIAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:122O FIFTH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-332-3002
Mailing Address - Fax:
Practice Address - Street 1:122O FIFTH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-332-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC19670207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0989964-01Medicaid
TX0989964-01Medicaid
TXC19670Medicare UPIN