Provider Demographics
NPI:1538115472
Name:JANGALA, CHESTER EDMOND (MD)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:EDMOND
Last Name:JANGALA
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 1:22443 SE 240TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5879
Mailing Address - Country:US
Mailing Address - Phone:425-432-9611
Mailing Address - Fax:206-973-5399
Practice Address - Street 1:22443 SE 240TH ST STE 203
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5879
Practice Address - Country:US
Practice Address - Phone:425-432-9611
Practice Address - Fax:206-973-5399
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA06144Medicare UPIN