Provider Demographics
NPI:1073719258
Name:CHAKRAVARTY, MIRA (MD)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:CHAKRAVARTY
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 1:3840 PARK AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2563
Mailing Address - Country:US
Mailing Address - Phone:732-494-9061
Mailing Address - Fax:732-494-5571
Practice Address - Street 1:3840 PARK AVENUE
Practice Address - Street 2:SUITE C
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820
Practice Address - Country:US
Practice Address - Phone:732-494-9061
Practice Address - Fax:732-494-5571
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03783000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE36080Medicare UPIN