Provider Demographics
NPI:1407120314
Name:CHAMARTHI, PHANI PRABHAKARA SRINIVASA SASTRY (MD)
Entity Type:Individual
Prefix:
First Name:PHANI PRABHAKARA
Middle Name:SRINIVASA SASTRY
Last Name:CHAMARTHI
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 1:2760 S ELM AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-5435
Mailing Address - Country:US
Mailing Address - Phone:559-457-5300
Mailing Address - Fax:559-457-5390
Practice Address - Street 1:2760 S ELM AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-5435
Practice Address - Country:US
Practice Address - Phone:559-457-5300
Practice Address - Fax:559-457-5390
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10034704208000000X
CAC148210208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB153263OtherMEDICARE