Provider Demographics
NPI:1669442141
Name:GUJRATHI, CHETAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:CHETAN
Middle Name:S
Last Name:GUJRATHI
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 1:4530 E SHEA BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6042
Mailing Address - Country:US
Mailing Address - Phone:602-264-4834
Mailing Address - Fax:602-254-5178
Practice Address - Street 1:4530 E SHEA BLVD STE 180
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6042
Practice Address - Country:US
Practice Address - Phone:602-264-4834
Practice Address - Fax:602-254-5178
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33545207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ799702Medicaid
AZ958978Medicaid
AZAZ153810OtherBC/BS PROVIDER ID
106523Medicare PIN
I12399Medicare UPIN