Provider Demographics
NPI:1235333956
Name:CHANDRAHASEGOWDA, SHASHINATH KATHARAGHATTA (MD)
Entity Type:Individual
Prefix:
First Name:SHASHINATH
Middle Name:KATHARAGHATTA
Last Name:CHANDRAHASEGOWDA
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 1:5041 UTICA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3480
Mailing Address - Country:US
Mailing Address - Phone:563-359-9696
Mailing Address - Fax:563-359-1730
Practice Address - Street 1:5041 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3480
Practice Address - Country:US
Practice Address - Phone:563-359-9696
Practice Address - Fax:563-359-1730
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK40318Medicare PIN