Healthcare Provider Details

I. General information

NPI: 1952614638
Provider Name (Legal Business Name): MARUT CHANTRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SW WILLISTON RD APT 1101
GAINESVILLE FL
32608-3961
US

IV. Provider business mailing address

2600 SW WILLISTON RD APT 1101
GAINESVILLE FL
32608-3961
US

V. Phone/Fax

Practice location:
  • Phone: 773-524-9887
  • Fax:
Mailing address:
  • Phone: 773-524-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: