Provider Demographics
NPI:1114944642
Name:GNANASHANMUGAM, CHINNIA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHINNIA
Middle Name:
Last Name:GNANASHANMUGAM
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 1:2400 HARBOR BLVD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5052
Mailing Address - Country:US
Mailing Address - Phone:941-625-6187
Mailing Address - Fax:941-625-7887
Practice Address - Street 1:2400 HARBOR BLVD
Practice Address - Street 2:SUITE 12
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5052
Practice Address - Country:US
Practice Address - Phone:941-625-6187
Practice Address - Fax:941-625-7887
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38376207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066348400Medicaid
D51980Medicare UPIN
08100Medicare PIN
FL066348400Medicaid