Provider Demographics
NPI:1598786725
Name:CHAKRABARTY, AMIT (MD)
Entity Type:Individual
Prefix:DR
First Name:AMIT
Middle Name:
Last Name:CHAKRABARTY
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 1:2400 LUCY LEE PKWY STE F
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2427
Mailing Address - Country:US
Mailing Address - Phone:573-609-2266
Mailing Address - Fax:573-785-0974
Practice Address - Street 1:2400 LUCY LEE PKWY STE F
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2427
Practice Address - Country:US
Practice Address - Phone:573-609-2266
Practice Address - Fax:573-785-0974
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70357208800000X
IN01058611A208800000X
MO2500020935208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935341Medicaid
AL000092909OtherMEDICARE
MO200018019Medicaid
AL51532618OtherBCBS
MOMA575101Medicare PIN