Provider Demographics
NPI:1659466225
Name:MANGALMURTI, CHAITANYA SURENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAITANYA
Middle Name:SURENDRA
Last Name:MANGALMURTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:12255 FAIR LAKES PKWY
Practice Address - Street 2:KAISER PERMANENTE FAIR OAKS MEDICAL CENTER
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3952
Practice Address - Country:US
Practice Address - Phone:703-934-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD31721208600000X
MDD0066199208600000X
TXJ4324208600000X
VA0101221322208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG50775Medicare UPIN
VA48818Medicare ID - Type Unspecified