Provider Demographics
NPI:1023090735
Name:CHANDRAMOULI, BASAVIAH (MD)
Entity type:Individual
Prefix:DR
First Name:BASAVIAH
Middle Name:
Last Name:CHANDRAMOULI
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 1:707 38TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-3177
Mailing Address - Country:US
Mailing Address - Phone:515-223-1511
Mailing Address - Fax:
Practice Address - Street 1:330 LAUREL ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3034
Practice Address - Country:US
Practice Address - Phone:515-288-1097
Practice Address - Fax:515-288-2847
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA190842080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1093849Medicaid
IA09384Medicare ID - Type Unspecified
IA1093849Medicaid