Provider Demographics
NPI:1659365856
Name:CHAKRABARTI, KISHANLAL (MD)
Entity Type:Individual
Prefix:DR
First Name:KISHANLAL
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 1:14 AVON RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4932
Mailing Address - Country:US
Mailing Address - Phone:617-539-1318
Mailing Address - Fax:866-274-0418
Practice Address - Street 1:120 BANKS ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-1931
Practice Address - Country:US
Practice Address - Phone:617-539-1318
Practice Address - Fax:866-274-0418
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA422162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2075059Medicaid
MAM09843Medicare UPIN