Provider Demographics
NPI:1518073451
Name:CHAUDHARI, PRAKASHCHANDRA JIVRAMBHAI (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASHCHANDRA
Middle Name:JIVRAMBHAI
Last Name:CHAUDHARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRAKASH
Other - Middle Name:J
Other - Last Name:CHAUDHARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 576768
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6768
Mailing Address - Country:US
Mailing Address - Phone:209-577-1200
Mailing Address - Fax:209-577-6517
Practice Address - Street 1:4301 N STAR WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356
Practice Address - Country:US
Practice Address - Phone:209-577-1200
Practice Address - Fax:209-577-6517
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8960207ZD0900X, 207ZP0102X
CAC52642207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200290424Medicaid
32664Medicare ID - Type Unspecified
NV200290424Medicaid