Basic Information
| Provider Information | |||||||||
| NPI: | 1164522082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAKRABORTY | ||||||||
| FirstName: | INDRANIL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 W MARKHAM ST #783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015266562 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST #783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015266562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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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 | 207L00000X | E-4315 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 5N445 | 01 | AR | BCBS | OTHER | 160491001 | 05 | AR | MEDICAID | E4315 | 01 | AR | TRICARE | OTHER | P00350630 | 01 | AR | RAILROAD MEDICARE 1 | OTHER | 06070015300 | 01 | AR | QUALCHOICE | OTHER |