Provider Demographics
NPI:1124283544
Name:CHITRA KUTHIALA MD PA
Entity type:Organization
Organization Name:CHITRA KUTHIALA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTHIALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:904-262-9135
Mailing Address - Street 1:9765 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-4402
Mailing Address - Country:US
Mailing Address - Phone:904-262-9135
Mailing Address - Fax:904-880-2948
Practice Address - Street 1:9765 SAN JOSE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-4402
Practice Address - Country:US
Practice Address - Phone:904-262-9135
Practice Address - Fax:904-880-2948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29708207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL192665OtherWELLCARE
FL192665OtherHEALTHEASE
FL265658200Medicaid
FL42736OtherBLUE CROSS BLUE SHIELD
FL2699245OtherAETNA
FL3464796-01OtherCIGNA
FL279638OtherAVMED
FL192665OtherWELLCARE
FL3464796-01OtherCIGNA