Provider Demographics
NPI:1720012974
Name:CHALAM, VENKATA (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:
Last Name:CHALAM
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 1:15101 SOUTHFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101
Mailing Address - Country:US
Mailing Address - Phone:313-386-3996
Mailing Address - Fax:313-386-5054
Practice Address - Street 1:15101 SOUTHFIELD ROAD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101
Practice Address - Country:US
Practice Address - Phone:313-386-3996
Practice Address - Fax:313-386-5054
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031397207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104790677Medicaid
N87830002Medicare ID - Type Unspecified
MI104790677Medicaid