Healthcare Provider Details

I. General information

NPI: 1184810905
Provider Name (Legal Business Name): LAKSHMI ISANAKA CHILLAKURU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2007
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 FAIRFIELD LOOP RD
CROWNSVILLE MD
21032-2006
US

IV. Provider business mailing address

PO BOX 778
EASTON MD
21601-8914
US

V. Phone/Fax

Practice location:
  • Phone: 410-987-6338
  • Fax:
Mailing address:
  • Phone: 410-763-8787
  • Fax: 443-496-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD67361
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: