MEDICARE: DR. CHANDRA K PUTTAGUNTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301035890	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861594525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANDRA K PUTTAGUNTA MD

Provider Business Mailing Address
First Line	:	1122 N LEROY ST
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-2789
Country	:	US
Telephone Number	:	810-629-8303
Fax Number	:	810-629-3949

Provider Business Practice Location Address
First Line	:	1122 N LEROY ST
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-2789
Country	:	US
Telephone Number	:	810-629-8303
Fax Number	:	810-629-3949

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	11/20/2011

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