Provider Demographics
NPI:1649299967
Name:CHANDRAN, NISHA (MD)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:CHANDRAN
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 1:621 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5077
Mailing Address - Country:US
Mailing Address - Phone:815-397-3350
Mailing Address - Fax:815-227-2992
Practice Address - Street 1:621 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5077
Practice Address - Country:US
Practice Address - Phone:815-397-3350
Practice Address - Fax:815-227-2992
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114562390200000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05632081OtherBLUE CROSS BLUE SHIELD
IL036114562Medicaid
IL07100059OtherIL HEALTH CONNECT