Provider Demographics
NPI:1063482321
Name:GORRELA, SUSHMA V (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSHMA
Middle Name:V
Last Name:GORRELA
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 1:6225 FM 2920 RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3474
Mailing Address - Country:US
Mailing Address - Phone:281-257-5977
Mailing Address - Fax:281-257-5966
Practice Address - Street 1:6225 FM 2920 RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3474
Practice Address - Country:US
Practice Address - Phone:281-257-5977
Practice Address - Fax:281-257-5966
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163557501Medicaid
TX8F8260Medicare PIN
TX8B2860Medicare PIN
TXH97569Medicare UPIN