Healthcare Provider Details

I. General information

NPI: 1417045527
Provider Name (Legal Business Name): SUMANT K CHAKRAVORTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W INDIANTOWN RD SUITE 106
JUPITER FL
33458-3556
US

IV. Provider business mailing address

5431 N UNIVERSITY DR
CORAL SPRINGS FL
33067-4639
US

V. Phone/Fax

Practice location:
  • Phone: 561-748-8103
  • Fax: 561-748-0773
Mailing address:
  • Phone: 954-344-2522
  • Fax: 954-344-9189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number650190533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: