Provider Demographics
NPI:1437164852
Name:CHAKRABORTTY, SHUSHOVAN (MD)
Entity type:Individual
Prefix:DR
First Name:SHUSHOVAN
Middle Name:
Last Name:CHAKRABORTTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N PARK BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3189
Mailing Address - Country:US
Mailing Address - Phone:248-929-8165
Mailing Address - Fax:248-929-8930
Practice Address - Street 1:425 N PARK BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3189
Practice Address - Country:US
Practice Address - Phone:248-929-8165
Practice Address - Fax:248-929-8930
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076099207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology