Basic Information
| Provider Information | |||||||||
| NPI: | 1275769168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENTHITTA | ||||||||
| FirstName: | ANIL | ||||||||
| MiddleName: | MATHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19450 DEERFIELD AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201766821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5715103815 | ||||||||
| FaxNumber: | 5715103675 | ||||||||
| Practice Location | |||||||||
| Address1: | 19450 DEERFIELD AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201766821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5715103815 | ||||||||
| FaxNumber: | 5715103675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2009 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | ME128763 | FL | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2081P2900X | 0101252929 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101252929 | 01 | VA | LICENSE NO | OTHER | 1275769168 | 05 | VA | MEDICAID | P01159671 | 01 | VA | RR MEDICARE | OTHER |