Provider Demographics
NPI:1134329782
Name:ALLI, CHAITANYA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAITANYA
Middle Name:
Last Name:ALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 SPACE PARK DR STE 302
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3675
Mailing Address - Country:US
Mailing Address - Phone:281-333-9747
Mailing Address - Fax:
Practice Address - Street 1:2060 SPACE PARK DR STE 302
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058
Practice Address - Country:US
Practice Address - Phone:281-333-9747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116017080207Q00000X
TXN0604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200874002Medicaid
TX1134329782OtherNPI