Provider Demographics
NPI:1790030195
Name:CHAKRAVARTY, BISHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BISHAN
Middle Name:
Last Name:CHAKRAVARTY
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 1:703 MAPLE VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640
Mailing Address - Country:US
Mailing Address - Phone:573-701-0470
Mailing Address - Fax:573-701-0473
Practice Address - Street 1:703 MAPLE VALLEY DRIVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-701-0470
Practice Address - Fax:573-701-0473
Is Sole Proprietor?:No
Enumeration Date:2012-07-21
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018009371207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200052190Medicaid