Provider Demographics
NPI:1992819676
Name:CHAKSUPA, DAN (MD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:CHAKSUPA
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:PO BOX 18563
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8563
Mailing Address - Country:US
Mailing Address - Phone:919-782-1806
Mailing Address - Fax:919-782-1669
Practice Address - Street 1:3521 HAWORTH DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7244
Practice Address - Country:US
Practice Address - Phone:919-782-1669
Practice Address - Fax:919-782-4756
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01602207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902990Medicaid
NCI50509Medicare UPIN
NC2051051Medicare ID - Type Unspecified
2051051EMedicare PIN
NC230575Medicare PIN