Provider Demographics
NPI:1801184767
Name:CHATURVEDULA, SURYA TEJA (MD)
Entity Type:Individual
Prefix:
First Name:SURYA TEJA
Middle Name:
Last Name:CHATURVEDULA
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 1:5409 N KNOXVILLE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5069
Mailing Address - Country:US
Mailing Address - Phone:309-672-4670
Mailing Address - Fax:309-672-4669
Practice Address - Street 1:5409 N KNOXVILLE AVE STE 207
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5069
Practice Address - Country:US
Practice Address - Phone:309-672-4670
Practice Address - Fax:309-672-4669
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.147477207RI0011X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology