Basic Information
| Provider Information | |||||||||
| NPI: | 1417242173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SURESH | ||||||||
| FirstName: | NANDITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SURESH | ||||||||
| OtherFirstName: | NANDITA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2640 E BARNETT RD | ||||||||
| Address2: | E333 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826770 | ||||||||
| FaxNumber: | 5412826771 | ||||||||
| Practice Location | |||||||||
| Address1: | 2825 E BARNETT ROAD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975040001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826770 | ||||||||
| FaxNumber: | 5412826771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT199204 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | MD166781 | OR | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | MD166781 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.