Provider Demographics
NPI:1134142821
Name:SUROWIEC, WALTER JOSPEH JR (DO,FACS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JOSPEH
Last Name:SUROWIEC
Suffix:JR
Gender:M
Credentials:DO,FACS
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1500
Mailing Address - Fax:228-575-1528
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:STE 420
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-1500
Practice Address - Fax:228-575-1528
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022945208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1498050Medicaid
LAPENDINGMedicare ID - Type Unspecified
LA1498050Medicaid