Provider Demographics
NPI:1881649101
Name:GATTU, KANCHANA (MD)
Entity Type:Individual
Prefix:
First Name:KANCHANA
Middle Name:
Last Name:GATTU
Suffix:
Gender:F
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:PO BOX 64374
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4374
Mailing Address - Country:US
Mailing Address - Phone:410-328-6331
Mailing Address - Fax:410-328-1674
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:S11C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6331
Practice Address - Fax:410-328-1674
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066603171100000X, 207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No171100000XOther Service ProvidersAcupuncturist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC11298OtherRAILROAD MEDICARE GROUP #
MD413314500Medicaid
MDR901Medicare PIN
MD413314500Medicaid
MDP00447834Medicare PIN
MDC11298OtherRAILROAD MEDICARE GROUP #
MDR902Medicare PIN
MD164931ZACHMedicare PIN