Healthcare Provider Details

I. General information

NPI: 1235333956
Provider Name (Legal Business Name): SHASHINATH KATHARAGHATTA CHANDRAHASEGOWDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5041 UTICA RIDGE RD
DAVENPORT IA
52807-3480
US

IV. Provider business mailing address

5041 UTICA RIDGE RD
DAVENPORT IA
52807-3480
US

V. Phone/Fax

Practice location:
  • Phone: 563-359-9696
  • Fax: 563-359-1730
Mailing address:
  • Phone: 563-359-9696
  • Fax: 563-359-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number37177
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: