Provider Demographics
NPI:1962463182
Name:CHANTRELLE, BARRY (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:CHANTRELLE
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 1:2844 SUMMIT ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3637
Mailing Address - Country:US
Mailing Address - Phone:510-922-1542
Mailing Address - Fax:510-922-9730
Practice Address - Street 1:2844 SUMMIT ST
Practice Address - Street 2:SUITE 104
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3637
Practice Address - Country:US
Practice Address - Phone:510-922-1542
Practice Address - Fax:510-922-9730
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35119174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G351190Medicaid
CA00G351190Medicaid
CA00G351190Medicare ID - Type Unspecified