Healthcare Provider Details

I. General information

NPI: 1780240911
Provider Name (Legal Business Name): CASSIA CHITLA CPED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 WATERDAM PLAZA DR STE 208
MC MURRAY PA
15317-5416
US

IV. Provider business mailing address

1400 KNIGHTS DR APT 311
SOUTH PARK PA
15129-8519
US

V. Phone/Fax

Practice location:
  • Phone: 480-734-4744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberPD000133
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: