Provider Demographics
NPI:1568252690
Name:CHALISE, SUJATA
Entity type:Individual
Prefix:
First Name:SUJATA
Middle Name:
Last Name:CHALISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 NORTH COUNTRY ROAD, PORT JEFFERSON, NY, 11777, MATHE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON, NY
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-686-2549
Mailing Address - Fax:
Practice Address - Street 1:75 NORTH COUNTRY ROAD, PORT JEFFERSON, NY, 11777, MATHE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON, NY
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-686-2549
Practice Address - Fax:631-476-2874
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program