Provider Demographics
NPI:1396713491
Name:CHANDRASEKHAR, KOLLAGUNTA SREENIVASA (MD)
Entity type:Individual
Prefix:DR
First Name:KOLLAGUNTA
Middle Name:SREENIVASA
Last Name:CHANDRASEKHAR
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 1:320 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4113
Mailing Address - Country:US
Mailing Address - Phone:863-508-1101
Mailing Address - Fax:863-299-6158
Practice Address - Street 1:320 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4113
Practice Address - Country:US
Practice Address - Phone:863-508-1101
Practice Address - Fax:863-299-6158
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64020207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372983400Medicaid
FL18806OtherBC BS
FL59629Medicare UPIN
FL18806VMedicare PIN
FL372983400Medicaid
FL372983400Medicaid