Provider Demographics
NPI:1093004384
Name:CHANTACHOTE, CHANAK (MD)
Entity Type:Individual
Prefix:
First Name:CHANAK
Middle Name:
Last Name:CHANTACHOTE
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:DEPARTMENT OF SURGERY
Mailing Address - Street 2:79 MIDDLEVILLE RD
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11725
Mailing Address - Country:US
Mailing Address - Phone:631-261-4400
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF SURGERY
Practice Address - Street 2:79 MIDDLEVILLE RD
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1432232086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery