Provider Demographics
NPI:1205823069
Name:CHAKRAVARTY, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:CHAKRAVARTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - Street 2:SUITE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:586-466-5230
Practice Address - Street 1:IHA PRIMARY CARE -FREEDOM
Practice Address - Street 2:20206 FARMINGTON RD
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:248-476-4724
Practice Address - Fax:313-416-1567
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2023-05-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301073432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I17915Medicare UPIN
MI4635535Medicaid
I17915Medicare UPIN