Provider Demographics
NPI:1528016490
Name:CHALLA, VIJAYA N (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:N
Last Name:CHALLA
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 1:7445 ALLEN RD
Mailing Address - Street 2:SUITE # 210
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1963
Mailing Address - Country:US
Mailing Address - Phone:313-382-0505
Mailing Address - Fax:313-382-1584
Practice Address - Street 1:7445 ALLEN RD
Practice Address - Street 2:SUITE # 210
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1963
Practice Address - Country:US
Practice Address - Phone:313-382-0505
Practice Address - Fax:313-382-1584
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4865150Medicaid
MII52277Medicare UPIN
MI4865150Medicaid