Provider Demographics
NPI: | 1760432363 |
---|---|
Name: | CHAMBERLAIN, DONALD HEASTON (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | DONALD |
Middle Name: | HEASTON |
Last Name: | CHAMBERLAIN |
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: | 1000 E 3RD ST |
Mailing Address - Street 2: | SUITE 201 |
Mailing Address - City: | CHATTANOOGA |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37403-2106 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-698-2050 |
Mailing Address - Fax: | 423-698-2095 |
Practice Address - Street 1: | 1000 E 3RD ST |
Practice Address - Street 2: | SUITE 201 |
Practice Address - City: | CHATTANOOGA |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37403-2106 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-698-2050 |
Practice Address - Fax: | 423-698-2095 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-12 |
Last Update Date: | 2019-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01078802A | 207VX0201X |
GA | 45182 | 207VX0201X |
TN | 30309 | 207VX0201X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 300003635 | Medicaid | |
GA | 98BBBCM | Medicare ID - Type Unspecified | |
IN | 300003635 | Medicaid |