Provider Demographics
NPI:1558344069
Name:DESARAJU, CHAKRADHAR (MD)
Entity Type:Individual
Prefix:
First Name:CHAKRADHAR
Middle Name:
Last Name:DESARAJU
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 1:3533 N LECANTO HWY
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3501
Mailing Address - Country:US
Mailing Address - Phone:352-795-6560
Mailing Address - Fax:
Practice Address - Street 1:6201 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6712
Practice Address - Country:US
Practice Address - Phone:352-795-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME93164OtherSTATE LICENSSE NUMBER
FL280320800Medicaid
FL29576OtherBCBS OF FL
FL9010415OtherCIGNA
FLP00294598OtherMEDICARE RR
FLU5681ZMedicare PIN
FLME93164OtherSTATE LICENSSE NUMBER