Provider Demographics
NPI:1104880392
Name:CHELAGIRI, MARIAMMA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIAMMA
Middle Name:
Last Name:CHELAGIRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIAMMA
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:STONY BROOK WTC WELLNESS PROGRAM,
Mailing Address - Street 2:500 COMMACK ROAD, SUITE 204
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5022
Mailing Address - Country:US
Mailing Address - Phone:631-855-1200
Mailing Address - Fax:631-630-6297
Practice Address - Street 1:500 COMMACK RD UNIT 204
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5022
Practice Address - Country:US
Practice Address - Phone:631-855-1200
Practice Address - Fax:631-630-6297
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1822S1Medicare ID - Type Unspecified
I48792Medicare UPIN