Provider Demographics
NPI:1760478853
Name:NALLARI, SURYA K (MD)
Entity Type:Individual
Prefix:DR
First Name:SURYA
Middle Name:K
Last Name:NALLARI
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 1:1608 LINCOLNWAY
Mailing Address - Street 2:STE G
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5852
Mailing Address - Country:US
Mailing Address - Phone:219-987-6010
Mailing Address - Fax:219-987-4546
Practice Address - Street 1:417 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9419
Practice Address - Country:US
Practice Address - Phone:219-987-6010
Practice Address - Fax:219-987-4546
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037891207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100143080AMedicaid
IN100143080AMedicaid
IN391520Medicare ID - Type Unspecified