Provider Demographics
NPI:1083773329
Name:KANDURU, CHAKRAVARTHY (MD)
Entity Type:Individual
Prefix:
First Name:CHAKRAVARTHY
Middle Name:
Last Name:KANDURU
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2825 LIVERNOIS
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083
Mailing Address - Country:US
Mailing Address - Phone:248-528-2310
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2825 LIVERNOIS
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-528-2310
Practice Address - Fax:248-528-8112
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI071718207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK071718OtherCHAMPUS-CHAMPUS
100H264400OtherBLUE CROSS-BLUE CROSS
CK071718OtherCOMMERCIAL-COMMERCIAL NUMBER
MI426710710Medicaid
MI426710710Medicaid
G73729Medicare UPIN