Basic Information
| Provider Information | |||||||||
| NPI: | 1487835229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILAKALA | ||||||||
| FirstName: | SANDEEP | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 853 JEFFERSON AVENUE, SUITE 201 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014484750 | ||||||||
| FaxNumber: | 9013022993 | ||||||||
| Practice Location | |||||||||
| Address1: | 853 JEFFERSON AVENUE, SUITE 201 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014484750 | ||||||||
| FaxNumber: | 9013022993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2007 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 49878 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1487835229 | 05 | MO | MEDICAID | 1532717 | 05 | TN | MEDICAID | 00422575 | 05 | MS | MEDICAID | 179200 | 05 | AL | MEDICAID | 196437001 | 05 | AR | MEDICAID | 003180578A | 05 | GA | MEDICAID |