Provider Demographics
NPI:1093208647
Name:BUKKAPATNAM, CHAITANYA (MD, MBA)
Entity Type:Individual
Prefix:
First Name:CHAITANYA
Middle Name:
Last Name:BUKKAPATNAM
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 RAVENS NEST CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1783
Mailing Address - Country:US
Mailing Address - Phone:614-670-2609
Mailing Address - Fax:
Practice Address - Street 1:881 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1713
Practice Address - Country:US
Practice Address - Phone:614-253-8537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72815-20208D00000X
WI7468851390200000X
OH35.146117208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program