Provider Demographics
NPI:1144213869
Name:LANKA, SURYA PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:SURYA
Middle Name:PRAKASH
Last Name:LANKA
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 1:2019B S HENDERSON BLVD
Mailing Address - Street 2:#12
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3546
Mailing Address - Country:US
Mailing Address - Phone:903-984-7512
Mailing Address - Fax:903-984-5336
Practice Address - Street 1:2019B S HENDERSON BLVD
Practice Address - Street 2:#12
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3546
Practice Address - Country:US
Practice Address - Phone:903-984-7512
Practice Address - Fax:903-984-5336
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4657207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F66985Medicare UPIN
TX00L51EMedicare ID - Type Unspecified