Healthcare Provider Details

I. General information

NPI: 1710211578
Provider Name (Legal Business Name): BHAVANI CHOUDARY SURYADEVARA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S BECKHAM AVE
TYLER TX
75701-1908
US

IV. Provider business mailing address

PO BOX 130549
TYLER TX
75713-0549
US

V. Phone/Fax

Practice location:
  • Phone: 903-590-5611
  • Fax: 903-535-6884
Mailing address:
  • Phone: 903-579-3931
  • Fax: 903-509-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52980
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number52980
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS8392
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: