Provider Demographics
NPI:1790769123
Name:CHAKRAVORTY, SUDEEP GOPAL (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDEEP
Middle Name:GOPAL
Last Name:CHAKRAVORTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10008 VALLEYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-7101
Mailing Address - Country:US
Mailing Address - Phone:724-934-0302
Mailing Address - Fax:724-934-0302
Practice Address - Street 1:10008 VALLEYVIEW CT
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-7101
Practice Address - Country:US
Practice Address - Phone:724-934-0302
Practice Address - Fax:724-934-0302
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 062000-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG 57921Medicare UPIN