Provider Demographics
NPI:1730162819
Name:CHALLA, SURYA K (MD)
Entity type:Individual
Prefix:
First Name:SURYA
Middle Name:K
Last Name:CHALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SURYA
Other - Middle Name:K
Other - Last Name:CHALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:232 GILMER ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3860
Mailing Address - Country:US
Mailing Address - Phone:336-347-7415
Mailing Address - Fax:336-347-7419
Practice Address - Street 1:1365 WESTGATE CENTER DR STE N1
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3106
Practice Address - Country:US
Practice Address - Phone:336-765-3337
Practice Address - Fax:336-765-3133
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC252412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC132VTOtherBCBS
NC3410016Medicaid
NC89132VTMedicaid
NC89132VTMedicaid
2010296Medicare PIN
NC2348105Medicare PIN
NC89132VTMedicaid
H72535Medicare UPIN