Basic Information
| Provider Information | |||||||||
| NPI: | 1912987082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANDRA | ||||||||
| FirstName: | MADHULIKA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367166674 | ||||||||
| FaxNumber: | 3367169188 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 WESTWOOD AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 200400308 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1912987082 | 05 | VA | MEDICAID | 89136T3 | 05 | NC | MEDICAID | 1285682310 | 01 | NC | WSCA GRP NPI # | OTHER | 136T3 | 01 | NC | BCBS ID# | OTHER | BC7914244 | 01 | FEDERAL DEA | OTHER | 804339 | 01 | NC | PARTNERS ID# | OTHER |