Provider Demographics
NPI:1104015387
Name:SURYAVANSHI, DILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:DILIP
Middle Name:
Last Name:SURYAVANSHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 HEALDSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3253
Mailing Address - Country:US
Mailing Address - Phone:707-473-4404
Mailing Address - Fax:707-473-4405
Practice Address - Street 1:1540 HEALDSBURG AVE
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3253
Practice Address - Country:US
Practice Address - Phone:707-473-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112298208600000X, 204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery