Provider Demographics
NPI:1467621110
Name:CHOUDHURI, INDRAJIT (MD)
Entity Type:Individual
Prefix:DR
First Name:INDRAJIT
Middle Name:
Last Name:CHOUDHURI
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:PHOENIXC HEALTHCARE S C
Mailing Address - Street 2:11168 NORTH LAKE SHORE DRIVE
Mailing Address - City:MEQUION
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:908-930-8866
Mailing Address - Fax:262-287-9898
Practice Address - Street 1:BELOIT HEALTH SYSTEM INC
Practice Address - Street 2:1969 WEST HART ROAD
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-364-5205
Practice Address - Fax:608-364-5593
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51309-020207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35129200Medicaid