Provider Demographics
NPI:1639292527
Name:SUDARSAN CHAVALA
Entity Type:Organization
Organization Name:SUDARSAN CHAVALA
Other - Org Name:MARYVILLE EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDARSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-562-2566
Mailing Address - Street 1:2024 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2655
Mailing Address - Country:US
Mailing Address - Phone:660-562-2566
Mailing Address - Fax:660-562-2432
Practice Address - Street 1:2024 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-2566
Practice Address - Fax:660-562-2432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8855207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO180023483OtherMEDICARE RAILROAD
MO321965204Medicaid
MO201965209Medicaid
MO22841019OtherBCBS OF KC
MO1315240001Medicare ID - Type UnspecifiedOPTICAL STORE
MO321965204Medicaid