Provider Demographics
NPI:1770773012
Name:RADHAKRISHNAN, CHITRA (MD)
Entity type:Individual
Prefix:
First Name:CHITRA
Middle Name:
Last Name:RADHAKRISHNAN
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 1:9201 4TH AVE STE 501
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7065
Mailing Address - Country:US
Mailing Address - Phone:718-921-2500
Mailing Address - Fax:718-238-2558
Practice Address - Street 1:9201 4TH AVE STE 501
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7065
Practice Address - Country:US
Practice Address - Phone:718-921-2500
Practice Address - Fax:718-238-2558
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.117757207W00000X
NY244377207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04901134OtherBLUE CROSS BLUE SHIELD OF IL
IL1770656787OtherGROUP NPI
ILDG5819OtherRAILROAD MEDICARE GROUP #
IL036117757Medicaid
IL1770773012OtherINDIVIDUAL NPI #
IL1770773012OtherINDIVIDUAL NPI #
ILK51044Medicare UPIN