Provider Demographics
NPI:1043461585
Name:GUDUR, SUMA (MD)
Entity Type:Individual
Prefix:
First Name:SUMA
Middle Name:
Last Name:GUDUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734538
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4538
Mailing Address - Country:US
Mailing Address - Phone:407-374-3455
Mailing Address - Fax:972-252-3019
Practice Address - Street 1:1705 COTTONWOOD VALLEY CIR S
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6212
Practice Address - Country:US
Practice Address - Phone:407-374-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105338207R00000X
GA70391207R00000X
TXP9361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMAID 001423800Medicaid
FLMCAR CL906ZMedicaid