Basic Information
| Provider Information | |||||||||
| NPI: | 1619264363 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURINDRA N. MITRUKA, M.D. A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 SOQUEL AVE | ||||||||
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| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950621323 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1575 SOQUEL DR | ||||||||
| Address2: | SUITE #C | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314586288 | ||||||||
| FaxNumber: | 8314779026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | DEGHETALDI | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/MD | ||||||||
| AuthorizedOfficialTelephone: | 8314585695 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | G84058 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.