Provider Demographics
NPI:1619080058
Name:CHAHAL, SUKHJIT S (MD)
Entity Type:Individual
Prefix:DR
First Name:SUKHJIT
Middle Name:S
Last Name:CHAHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:SUPERNAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OFFICE MANAGER
Mailing Address - Street 1:7011 N HOWARD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2955
Mailing Address - Country:US
Mailing Address - Phone:559-935-5491
Mailing Address - Fax:559-935-5719
Practice Address - Street 1:7011 N HOWARD ST
Practice Address - Street 2:STE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2955
Practice Address - Country:US
Practice Address - Phone:559-935-5491
Practice Address - Fax:559-935-5719
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36802174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A368020Medicaid
CA942880072OtherTAX IDENTIFICATION NUMBER
CA00A368020Medicare ID - Type Unspecified
CA00A368020Medicaid