Provider Demographics
NPI:1104407816
Name:CHAHAL, SUPREET KAUR (MD)
Entity type:Individual
Prefix:
First Name:SUPREET
Middle Name:KAUR
Last Name:CHAHAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9227 S WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-9261
Mailing Address - Country:US
Mailing Address - Phone:559-618-2677
Mailing Address - Fax:
Practice Address - Street 1:4676 ADMIRALTY WAY FL 4
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6601
Practice Address - Country:US
Practice Address - Phone:424-314-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA193704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program