Basic Information
Provider Information | |||||||||
NPI: | 1942523626 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAKRALA | ||||||||
FirstName: | KALYAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2129 | ||||||||
Address2: |   | ||||||||
City: | ODESSA | ||||||||
State: | TX | ||||||||
PostalCode: | 797602129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4326403007 | ||||||||
FaxNumber: | 4326402708 | ||||||||
Practice Location | |||||||||
Address1: | 540 W 5TH ST STE 300 | ||||||||
Address2: |   | ||||||||
City: | ODESSA | ||||||||
State: | TX | ||||||||
PostalCode: | 79761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4326403007 | ||||||||
FaxNumber: | 4326402708 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2010 | ||||||||
LastUpdateDate: | 09/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N5612 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 335941602 | 05 | TX |   | MEDICAID |