Individual
CHANDRAMOHAN G MUDALIAR
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
122O FIFTH AVE, FORT WORTH, TX 76104
(817) 332-3002
Mailing address
122O FIFTH AVE, FORT WORTH, TX 76104
(817) 332-3002
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
C19670
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0989964-01
—
TX
Enumeration date
02/14/2006
Last updated
11/17/2009
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