Healthcare Provider Details

I. General information

NPI: 1629332218
Provider Name (Legal Business Name): VIJAYA CHALLA, M.D.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24604 MICHIGAN AVE STE 100
DEARBORN MI
48124-1760
US

IV. Provider business mailing address

24604 MICHIGAN AVE STE 100
DEARBORN MI
48124-1760
US

V. Phone/Fax

Practice location:
  • Phone: 313-562-9020
  • Fax: 313-562-8511
Mailing address:
  • Phone: 313-562-9020
  • Fax: 313-562-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberVC080035
License Number StateMI

VIII. Authorized Official

Name: VENKY R CHALLA
Title or Position: OFFICE MANAGER
Credential:
Phone: 313-562-9020