Provider Demographics
NPI:1881654085
Name:THANNIKKARY, CHANCHAMMA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANCHAMMA
Middle Name:
Last Name:THANNIKKARY
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:212 SMITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4914
Practice Address - Country:US
Practice Address - Phone:252-537-1717
Practice Address - Fax:252-537-1366
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320572085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01269393OtherRAILROAD MCR
NC1881654085Medicaid
NC3722179OtherCIGNA
NC5760043OtherAETNA
VA1881654085Medicaid
NC8982452Medicaid
NC3722179OtherCIGNA
NC5760043OtherAETNA
NCC43313Medicare UPIN