Provider Demographics
NPI:1558467373
Name:KANTA, CHANDER (MD)
Entity Type:Individual
Prefix:
First Name:CHANDER
Middle Name:
Last Name:KANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26328 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1215
Mailing Address - Country:US
Mailing Address - Phone:586-758-3210
Mailing Address - Fax:586-758-3233
Practice Address - Street 1:26328 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1215
Practice Address - Country:US
Practice Address - Phone:586-758-3210
Practice Address - Fax:586-758-3233
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104509549Medicaid
MI104509549Medicaid
0N73300Medicare ID - Type Unspecified