Provider Demographics
NPI:1275083263
Name:CHERYALA, MAHESH
Entity Type:Individual
Prefix:
First Name:MAHESH
Middle Name:
Last Name:CHERYALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-2401
Mailing Address - Country:US
Mailing Address - Phone:570-343-2383
Mailing Address - Fax:
Practice Address - Street 1:5 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JERMYN
Practice Address - State:PA
Practice Address - Zip Code:18433-1121
Practice Address - Country:US
Practice Address - Phone:570-230-0019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT211770390200000X
PAMD469367207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine