Basic Information
| Provider Information | |||||||||
| NPI: | 1548230758 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILAKAMARRI | ||||||||
| FirstName: | VIJAY | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | MEDPARTNERS, ATTN: BARB COPELAND | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7916 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604322297 | ||||||||
| FaxNumber: | 2604346433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 01056190A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 01056190A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 000000221081 | 01 | IN | ATHEM | OTHER | 200376810 | 05 | IN | MEDICAID | P00783746 | 01 | IN | RAILROAD | OTHER | 060068441 | 01 | RAILROAD | OTHER | 2322123 | 05 | OH | MEDICAID |