Basic Information
| Provider Information | |||||||||
| NPI: | 1255951588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILLA | ||||||||
| FirstName: | DEEPAK | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 SIXTH ST SW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303635434 | ||||||||
| FaxNumber: | 3303633877 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 SIXTH ST SW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303635434 | ||||||||
| FaxNumber: | 3303633877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2020 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.