1700098852 NPI number — SUJA JOHNKUTTY, M.D., P.L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700098852 NPI number — SUJA JOHNKUTTY, M.D., P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUJA JOHNKUTTY, M.D., P.L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700098852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 224
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD BETHPAGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11804-0224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-385-8558
Provider Business Mailing Address Fax Number:
631-385-8010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 WALT WHITMAN ROAD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
HUNTINGTON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11746-4276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-385-8558
Provider Business Practice Location Address Fax Number:
631-385-8010
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNKUTTY
Authorized Official First Name:
SUJA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
631-385-8558

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 216285 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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