Basic Information
Provider Information | |||||||||
NPI: | 1730162819 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHALLA | ||||||||
FirstName: | SURYA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHALLA | ||||||||
OtherFirstName: | SURYA | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 232 GILMER ST | ||||||||
Address2: | SUITE 206 | ||||||||
City: | REIDSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 273203860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363477415 | ||||||||
FaxNumber: | 3363477419 | ||||||||
Practice Location | |||||||||
Address1: | 1365 WESTGATE CENTER DR STE N1 | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271033106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367653337 | ||||||||
FaxNumber: | 3367653133 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2005 | ||||||||
LastUpdateDate: | 11/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25241 | NC | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 132VT | 01 | NC | BCBS | OTHER | 3410016 | 05 | NC |   | MEDICAID | BC7859006 | 01 | NC | DEA | OTHER | 89132VT | 05 | NC |   | MEDICAID |