Provider Demographics
NPI:1457508079
Name:CHANNAPPA, CHAITRA (MBBS)
Entity Type:Individual
Prefix:DR
First Name:CHAITRA
Middle Name:
Last Name:CHANNAPPA
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HOME DEPOT DR STE 283
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2669
Mailing Address - Country:US
Mailing Address - Phone:774-343-2432
Mailing Address - Fax:
Practice Address - Street 1:31 HOME DEPOT DR STE 283
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2669
Practice Address - Country:US
Practice Address - Phone:774-343-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00450207Q00000X
IAR-8277207Q00000X
MA271152207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2013-00450OtherLICENSE
MA271152OtherMA MEDICAL LICENSE BOARD