MEDICARE: DR. CHANDANA BOPITIYA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	ME26460	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	58259	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1689675191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANDANA BOPITIYA M.D.

Provider Business Mailing Address
First Line	:	2350 SCENIC DR
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34293-1510
Country	:	US
Telephone Number	:	941-584-0043
Fax Number	:	941-496-8627

Provider Business Practice Location Address
First Line	:	2350 SCENIC DR
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34293-1510
Country	:	US
Telephone Number	:	941-584-0043
Fax Number	:	941-496-8627

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	01/16/2008

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