Provider Demographics
NPI:1417079393
Name:KANNAMANGALA CHANDRASHEKAR, SUJAY KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SUJAY KUMAR
Middle Name:
Last Name:KANNAMANGALA CHANDRASHEKAR
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 1:127 CRESTVIEW PARK DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2855
Mailing Address - Country:US
Mailing Address - Phone:615-446-5121
Mailing Address - Fax:615-446-1357
Practice Address - Street 1:758 HIGHWAY 46 S
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2556
Practice Address - Country:US
Practice Address - Phone:615-446-2708
Practice Address - Fax:615-446-1357
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD54596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022894Medicaid
TNMD54596OtherMEDICAL LICENSE
TNQ022894Medicaid