1073626503 NPI number — SURENDER VUTHOORI MD INC

Table of content: (NPI 1073626503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073626503 NPI number — SURENDER VUTHOORI MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURENDER VUTHOORI MD INC
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:
1073626503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 168
Provider Second Line Business Mailing Address:
63532 29 PALMS HWY STE A
Provider Business Mailing Address City Name:
JOSHUA TREE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-366-8491
Provider Business Mailing Address Fax Number:
760-346-2471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
63532 29 PALMS HWY
Provider Second Line Business Practice Location Address:
#A
Provider Business Practice Location Address City Name:
JOSHUA TREE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-366-8491
Provider Business Practice Location Address Fax Number:
760-346-2471
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VUTHOORI
Authorized Official First Name:
SURENDER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-366-8491

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  A33804 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 913622300 . This is a "MEDFL MEDICAL FLORIDA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 199003100 . This is a "US LAB US DEPARTMENT OF LABOUR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A338040 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 199003100 . This is a "ACSTA ACS DEPARTMENT OF LABOUR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 756061629 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ89656Z . This is a "MEDICARE ID TYPE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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