Provider Demographics
NPI:1710211578
Name:SURYADEVARA, BHAVANI CHOUDARY (MD)
Entity Type:Individual
Prefix:DR
First Name:BHAVANI
Middle Name:CHOUDARY
Last Name:SURYADEVARA
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:PO BOX 130549
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0549
Mailing Address - Country:US
Mailing Address - Phone:903-579-3931
Mailing Address - Fax:903-509-5835
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-590-5611
Practice Address - Fax:903-535-6884
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO52980207R00000X, 208M00000X
TXS8392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57137285Medicaid
CO57137285Medicaid