Provider Demographics
NPI:1316936610
Name:CHALLA, SURYA (MD)
Entity type:Individual
Prefix:
First Name:SURYA
Middle Name:
Last Name:CHALLA
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 1:300 MEDICAL PKWY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4985
Mailing Address - Country:US
Mailing Address - Phone:757-819-7633
Mailing Address - Fax:757-819-7665
Practice Address - Street 1:300 MEDICAL PKWY
Practice Address - Street 2:SUITE 208
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4985
Practice Address - Country:US
Practice Address - Phone:757-819-7633
Practice Address - Fax:757-819-7665
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233830208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA246704OtherANTHEM
VA10014218OtherSENTARA
NC5905675Medicaid
VA205575330OtherTRICARE
VA2501166OtherCIGNA
VA010332516Medicaid
VA7626158OtherAETNA
VAP00386516OtherRR MEDICARE
VA010332516Medicaid
VA00X161S01Medicare PIN