Healthcare Provider Details

I. General information

NPI: 1417744616
Provider Name (Legal Business Name): CHAITANYA SWAROOP PUVVADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR COLUMBIA ST. MARY'S HOSPITAL
MILWAUKEE WI
53211
US

IV. Provider business mailing address

2400 W. VILLARD AVENUE MS. SANDRA OLSEN
MILWAUKEE WI
53209
US

V. Phone/Fax

Practice location:
  • Phone: 414-737-6170
  • Fax:
Mailing address:
  • Phone: 414-527-8415
  • 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: