Provider Demographics
NPI:1902427651
Name:UNDAVALLI, CHAITANYA
Entity type:Individual
Prefix:
First Name:CHAITANYA
Middle Name:
Last Name:UNDAVALLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:844-630-0700
Mailing Address - Fax:877-374-1924
Practice Address - Street 1:2900 E TEXAS ST STE 100
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3275
Practice Address - Country:US
Practice Address - Phone:318-606-6737
Practice Address - Fax:833-749-0343
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP20085227390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program