Provider Demographics
NPI:1578634309
Name:CHAKRABARTI, SUJIT (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJIT
Middle Name:
Last Name:CHAKRABARTI
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 1:145 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4058
Mailing Address - Country:US
Mailing Address - Phone:718-720-9670
Mailing Address - Fax:
Practice Address - Street 1:145 GRAND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4058
Practice Address - Country:US
Practice Address - Phone:718-720-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111181208600000X
CAC52332208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00199293Medicaid
NY661571Medicare ID - Type Unspecified
NY00199293Medicaid