Provider Demographics
NPI:1851007553
Name:ANAVALAMUDI THYAGARAJ, CHANDRA SHEKAR BABU
Entity Type:Individual
Prefix:
First Name:CHANDRA SHEKAR BABU
Middle Name:
Last Name:ANAVALAMUDI THYAGARAJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8386 N MISSIONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8386 N MISSIONWOOD CIR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2935
Practice Address - Country:US
Practice Address - Phone:954-683-3617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11019662363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36176139Medicaid