Provider Demographics
NPI:1992730881
Name:AMARAM, CHANDRAKANTH (MD)
Entity type:Individual
Prefix:
First Name:CHANDRAKANTH
Middle Name:
Last Name:AMARAM
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 1:302 UVALDA ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4551
Mailing Address - Country:US
Mailing Address - Phone:912-285-2519
Mailing Address - Fax:912-284-2482
Practice Address - Street 1:302 UVALDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4551
Practice Address - Country:US
Practice Address - Phone:912-285-2519
Practice Address - Fax:912-284-2482
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043158174400000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000804372DMedicaid
GA000804372AMedicaid
GA000804372EMedicaid
GA000804372DMedicaid