Provider Demographics
NPI:1053606707
Name:CHAKRAVARTHY, MITHUN (MD)
Entity type:Individual
Prefix:
First Name:MITHUN
Middle Name:
Last Name:CHAKRAVARTHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 E NORTH AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4740
Mailing Address - Country:US
Mailing Address - Phone:412-359-5822
Mailing Address - Fax:412-359-6620
Practice Address - Street 1:490 E NORTH AVE STE 307
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4740
Practice Address - Country:US
Practice Address - Phone:412-359-5822
Practice Address - Fax:412-359-6620
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD438934207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021344Medicaid
OH3158998Medicaid
PA1026053420001Medicaid
OH3158998Medicaid
PAP00991135Medicare PIN
PA220321QJDMedicare PIN