Provider Demographics
NPI:1073626503
Name:SURENDER VUTHOORI MD INC
Entity Type:Organization
Organization Name:SURENDER VUTHOORI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SURENDER
Authorized Official - Middle Name:
Authorized Official - Last Name:VUTHOORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-366-8491
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:63532 29 PALMS HWY STE A
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252
Mailing Address - Country:US
Mailing Address - Phone:760-366-8491
Mailing Address - Fax:760-346-2471
Practice Address - Street 1:63532 29 PALMS HWY
Practice Address - Street 2:#A
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252
Practice Address - Country:US
Practice Address - Phone:760-366-8491
Practice Address - Fax:760-346-2471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURENDER VUTHOORI MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33804207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA913622300OtherMEDFL MEDICAL FLORIDA
CA199003100OtherUS LAB US DEPARTMENT OF LABOUR
CA00A338040Medicaid
CA199003100OtherACSTA ACS DEPARTMENT OF LABOUR
CA756061629OtherMEDICARE RAILROAD
CAZZZ89656ZOtherMEDICARE ID TYPE
CA913622300OtherMEDFL MEDICAL FLORIDA