Provider Demographics
NPI:1861594525
Name:PUTTAGUNTA, CHANDRA K (MD)
Entity type:Individual
Prefix:DR
First Name:CHANDRA
Middle Name:K
Last Name:PUTTAGUNTA
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 1:1122 N LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2789
Mailing Address - Country:US
Mailing Address - Phone:810-629-8303
Mailing Address - Fax:810-629-3949
Practice Address - Street 1:1122 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2789
Practice Address - Country:US
Practice Address - Phone:810-629-8303
Practice Address - Fax:810-629-3949
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3235851Medicaid
MI3235851Medicaid
MIM23560044Medicare PIN