Provider Demographics
NPI:1770532624
Name:CHADALAWADA, PURNA L (MD)
Entity type:Individual
Prefix:
First Name:PURNA
Middle Name:L
Last Name:CHADALAWADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PURNA
Other - Middle Name:LAKSHMIBASAVA
Other - Last Name:CHADALAWADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:808 COMMERCE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296
Mailing Address - Country:US
Mailing Address - Phone:770-996-9191
Mailing Address - Fax:770-996-5298
Practice Address - Street 1:808 COMMERCE BLVD
Practice Address - Street 2:STE A
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296
Practice Address - Country:US
Practice Address - Phone:770-996-9191
Practice Address - Fax:770-996-5298
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047412208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00893285AMedicaid
GA00893285AMedicaid