Provider Demographics
NPI:1972555977
Name:INDIRA, CHANNAKESHAVA RAYAN (MD)
Entity type:Individual
Prefix:
First Name:CHANNAKESHAVA
Middle Name:RAYAN
Last Name:INDIRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:
Other - Last Name:INDIRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4370 FASHION SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5221
Mailing Address - Country:US
Mailing Address - Phone:989-799-5441
Mailing Address - Fax:989-799-3590
Practice Address - Street 1:4370 FASHION SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-5221
Practice Address - Country:US
Practice Address - Phone:989-799-5441
Practice Address - Fax:989-799-3590
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICI040238207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0731263Medicare ID - Type Unspecified
MIBI47287Medicare UPIN