Basic Information
| Provider Information | |||||||||
| NPI: | 1407120314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMARTHI | ||||||||
| FirstName: | PHANI PRABHAKARA | ||||||||
| MiddleName: | SRINIVASA SASTRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 ALBERTA AVE | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155456720 | ||||||||
| FaxNumber: | 9155455755 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 ALBERTA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155458826 | ||||||||
| FaxNumber: | 9155456975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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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 | 208000000X | BP10034704 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | TXB153263 | 01 | TX | MEDICARE | OTHER |