Provider Demographics
NPI:1649001074
Name:PANERU, CHANDRA PRASAD
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:PRASAD
Last Name:PANERU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 W OGDEN AVE APT UNIT910
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7068
Mailing Address - Country:US
Mailing Address - Phone:312-479-1905
Mailing Address - Fax:
Practice Address - Street 1:1901 W HARRISON ST FL 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250831202080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine