Provider Demographics
NPI:1386635365
Name:CHODISETTY, SUBRAHMANYAM (MD,)
Entity Type:Individual
Prefix:
First Name:SUBRAHMANYAM
Middle Name:
Last Name:CHODISETTY
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 1:3949 SUNFOREST CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4473
Mailing Address - Country:US
Mailing Address - Phone:419-475-9341
Mailing Address - Fax:419-475-2761
Practice Address - Street 1:3949 SUNFOREST CT
Practice Address - Street 2:SUITE 105
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4473
Practice Address - Country:US
Practice Address - Phone:419-475-9341
Practice Address - Fax:419-475-2761
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350803742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2298062Medicaid
OHH55925Medicare UPIN
OH4069911Medicare ID - Type Unspecified