Healthcare Provider Details

I. General information

NPI: 1770520199
Provider Name (Legal Business Name): VALLATHUCHERRY CHAKALAKUMBIL HARISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 WESTWOOD AVE
HIGH POINT NC
27262-4324
US

IV. Provider business mailing address

624 QUAKER LN STE. 207C
HIGH POINT NC
27262-3832
US

V. Phone/Fax

Practice location:
  • Phone: 336-781-4080
  • Fax: 336-781-4081
Mailing address:
  • Phone: 336-883-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number200300155
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5903850
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: