Provider Demographics
NPI:1083059455
Name:SUVARNASUDDHI, KHETISUDA (MD)
Entity Type:Individual
Prefix:
First Name:KHETISUDA
Middle Name:
Last Name:SUVARNASUDDHI
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 1:593 EDDY STREET, APC 942
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-7752
Mailing Address - Country:US
Mailing Address - Phone:401-444-5445
Mailing Address - Fax:401-444-9822
Practice Address - Street 1:12931 OAK HILL AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-797-9600
Practice Address - Fax:301-797-3854
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03684207RN0300X
390200000X
MDD0085666207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD520968642Medicaid