Healthcare Provider Details

I. General information

NPI: 1629142815
Provider Name (Legal Business Name): CHALLA AJIT, M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 DERR RD
SPRINGFIELD OH
45503-2433
US

IV. Provider business mailing address

2355 DERR RD
SPRINGFIELD OH
45503-2433
US

V. Phone/Fax

Practice location:
  • Phone: 937-568-7070
  • Fax: 937-629-3285
Mailing address:
  • Phone: 937-568-7070
  • Fax: 937-629-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35082392
License Number StateOH

VIII. Authorized Official

Name: CHALLA AJIT
Title or Position: OWNER
Credential: M.D.
Phone: 937-568-7070