Provider Demographics
NPI:1558475517
Name:KELWALA, SURENDRA (MD)
Entity Type:Individual
Prefix:
First Name:SURENDRA
Middle Name:
Last Name:KELWALA
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 1:36180 FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1919
Mailing Address - Country:US
Mailing Address - Phone:734-591-7666
Mailing Address - Fax:734-591-2426
Practice Address - Street 1:36180 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1919
Practice Address - Country:US
Practice Address - Phone:734-591-7666
Practice Address - Fax:734-591-2426
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010439722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A73304Medicare UPIN
MI0824393326Medicare ID - Type Unspecified