Basic Information
| Provider Information | |||||||||
| NPI: | 1992819676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAKSUPA | ||||||||
| FirstName: | DAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18563 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276198563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197821806 | ||||||||
| FaxNumber: | 9197821669 | ||||||||
| Practice Location | |||||||||
| Address1: | 3521 HAWORTH DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197821669 | ||||||||
| FaxNumber: | 9197824756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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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 | 207R00000X | 2005-01602 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5902990 | 05 | NC | MEDICAID |