Provider Demographics
NPI:1659668218
Name:CHAGANABOYANA, SULABHA (MD)
Entity Type:Individual
Prefix:
First Name:SULABHA
Middle Name:
Last Name:CHAGANABOYANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-7869
Practice Address - Street 1:465 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-234-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26025207Q00000X
KS94-07773207Q00000X
IDM13891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV4855BMedicare UPIN
WVWV4855AMedicare Oscar/Certification
WVWV4855DMedicare PIN