Provider Demographics
NPI:1891788741
Name:KISHORE, CHADALAVADA N (MD)
Entity Type:Individual
Prefix:DR
First Name:CHADALAVADA
Middle Name:N
Last Name:KISHORE
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:PO BOX 84009
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-4009
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:229-312-5853
Practice Address - Street 1:425 THIRD AVE
Practice Address - Street 2:STE 340
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701
Practice Address - Country:US
Practice Address - Phone:229-312-9150
Practice Address - Fax:229-435-5590
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA27846204C00000X
GA027846207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00312881AMedicaid
GA000312881CMedicaid
GAGRP3304Medicare ID - Type Unspecified
A83425Medicare UPIN
GAA83425Medicare UPIN