Provider Demographics
NPI:1295761641
Name:CHAKRAVORTY, UTPAL U (MD)
Entity type:Individual
Prefix:DR
First Name:UTPAL
Middle Name:U
Last Name:CHAKRAVORTY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-6600
Mailing Address - Fax:701-364-6628
Practice Address - Street 1:1282 WALNUT ST
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:MN
Practice Address - Zip Code:56232-2333
Practice Address - Country:US
Practice Address - Phone:320-312-2118
Practice Address - Fax:320-769-2972
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2019-11-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN38604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN909316800Medicaid
MN909316800Medicaid