Provider Demographics
NPI:1134126048
Name:CHAKRAVARTY, SUPRIYA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:
Last Name:CHAKRAVARTY
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 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-865-3939
Mailing Address - Fax:
Practice Address - Street 1:4235 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4231
Practice Address - Country:US
Practice Address - Phone:419-865-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040780207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060070243OtherRAILROAD MEDICARE
OHP00181418OtherOHIO RAILROAD MEDICARE
A76386Medicare UPIN
MI0N11220016Medicare PIN
060070243OtherRAILROAD MEDICARE