Provider Demographics
NPI:1770635682
Name:GOTTIPATI, CHANDRA S (MBBS)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:S
Last Name:GOTTIPATI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-4331
Mailing Address - Country:US
Mailing Address - Phone:218-683-4600
Mailing Address - Fax:218-681-8487
Practice Address - Street 1:1720 HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4331
Practice Address - Country:US
Practice Address - Phone:218-681-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1050984OtherPREFERREDONE
ND14261Medicaid
ND28770OtherND BCBS
MN547652000Medicaid
HP80578OtherHEALTHPARTNERS
0127049OtherMEDICA
ND14261Medicaid