Provider Demographics
NPI:1043377062
Name:CHALLA, KISHORE K (MD, FACC)
Entity type:Individual
Prefix:DR
First Name:KISHORE
Middle Name:K
Last Name:CHALLA
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Gender:M
Credentials:MD, FACC
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Mailing Address - Street 1:4607 MACCORKLE AVENUE SW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-766-3688
Mailing Address - Fax:304-766-3484
Practice Address - Street 1:4607 MACCORKLE AVENUE SW
Practice Address - Street 2:SUITE 300
Practice Address - City:SO CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-766-3688
Practice Address - Fax:304-766-3484
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2022-05-10
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV15721207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0085683000Medicaid
WVA61863Medicare UPIN