Provider Demographics
NPI:1740236306
Name:CHALAKA, SRIDAR (MD)
Entity Type:Individual
Prefix:
First Name:SRIDAR
Middle Name:
Last Name:CHALAKA
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-339-5410
Practice Address - Fax:425-257-1433
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034833207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8207292Medicaid
WA0114209OtherLABOR AND INDUSTRY
WA1017776Medicaid
WA290009806OtherRAILROAD MEDICARE
WAMD00034833OtherSTATE LICENSE NUMBER
F64751Medicare UPIN
WAG8901019Medicare PIN
WAG8880217Medicare PIN
WAAB00303Medicare PIN