MEDICARE: PURNA L CHADALAWADA MD

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	208000000X	Pediatrics Physician	047412	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770532624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PURNA L CHADALAWADA MD

Provider Business Mailing Address
First Line	:	808 COMMERCE BLVD
Second Line	:	STE A
City	:	RIVERDALE
State	:	GA
Zip	:	30296
Country	:	US
Telephone Number	:	770-996-9191
Fax Number	:	770-996-5298

Provider Business Practice Location Address
First Line	:	808 COMMERCE BLVD
Second Line	:	STE A
City	:	RIVERDALE
State	:	GA
Zip	:	30296
Country	:	US
Telephone Number	:	770-996-9191
Fax Number	:	770-996-5298

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	09/29/2011

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