Provider Demographics
NPI:1417683756
Name:CHAKRABORTY, SHUDIPAN
Entity Type:Individual
Prefix:
First Name:SHUDIPAN
Middle Name:
Last Name:CHAKRABORTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1402
Mailing Address - Country:US
Mailing Address - Phone:419-251-2360
Mailing Address - Fax:
Practice Address - Street 1:MERCY ST. VINCENT MEDICAL CENTER
Practice Address - Street 2:2213 CHERRY STREET, ACC BUILDING, 1ST FLOOR TOLEDO, O
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608
Practice Address - Country:US
Practice Address - Phone:419-251-4744
Practice Address - Fax:419-251-6795
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program