Provider Demographics
NPI:1720063100
Name:CHIANG, MIKE SYRU (MD)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:SYRU
Last Name:CHIANG
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 1:3294 NORTH OAK STREET EXT
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-241-1188
Mailing Address - Fax:229-245-7106
Practice Address - Street 1:3294 NORTH OAK STREET EXT.
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605
Practice Address - Country:US
Practice Address - Phone:229-241-1188
Practice Address - Fax:229-245-7106
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018627208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340005901OtherMEDICARE RAILROAD
GA000244791BMedicaid
GAD39589Medicare UPIN
GA34BDBNBMedicare PIN