Provider Demographics
NPI:1548230113
Name:VAVILALA, CHANDANA (MD)
Entity type:Individual
Prefix:
First Name:CHANDANA
Middle Name:
Last Name:VAVILALA
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:10860 MAPLE LN
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8418
Practice Address - Country:US
Practice Address - Phone:219-365-7000
Practice Address - Fax:219-365-2609
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057596A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200496780Medicaid
IN00000072193OtherANTHEM TRADITIONAL
INI25504Medicare UPIN
INM400061865Medicare PIN
IN202790SSMedicare PIN