Basic Information
| Provider Information | |||||||||
| NPI: | 1861590382 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRUKA | ||||||||
| FirstName: | SURINDRA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 SOQUEL AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950621323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314586603 | ||||||||
| FaxNumber: | 8314586293 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 SOQUEL DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314586288 | ||||||||
| FaxNumber: | 8314779026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | G84058 | CA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 00G840580 | 05 | CA | MEDICAID |