Provider Demographics
NPI:1013999218
Name:CHOWDHURY, PUSHAN (MD)
Entity Type:Individual
Prefix:
First Name:PUSHAN
Middle Name:
Last Name:CHOWDHURY
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 1:2055 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2055 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3111
Practice Address - Country:US
Practice Address - Phone:186-698-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33097208000000X
CAC55148208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ908163Medicaid