Basic Information
| Provider Information | |||||||||
| NPI: | 1841232493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANDA | ||||||||
| FirstName: | JAYASREE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEBNATH | ||||||||
| OtherFirstName: | JAYASREE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 212 E 106 STREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123602600 | ||||||||
| FaxNumber: | 6466198399 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 E 106 STREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123602600 | ||||||||
| FaxNumber: | 6466198399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD29888 | TN | N | Other Service Providers | Specialist | 207Q00000X | MD29888 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | MD29888 | TN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | 198279 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 198279-1 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3855243 | 05 | TN | MEDICAID | 4121982 | 01 | TN | TENNCARE SELECT | OTHER | 14891 | 01 | TN | TLC FAMILY HEALTHCARE | OTHER | 621821584 | 01 | TN | TRICARE | OTHER | 6848718 | 01 | TN | CIGNA | OTHER | 4121982 | 01 | TN | BLUE CROSS BLUE SHEILD | OTHER |