Provider Demographics
NPI:1184826968
Name:ANUMUKONDA, SUSMITHA (MBBH)
Entity Type:Individual
Prefix:
First Name:SUSMITHA
Middle Name:
Last Name:ANUMUKONDA
Suffix:
Gender:F
Credentials:MBBH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3112
Mailing Address - Country:US
Mailing Address - Phone:318-212-5437
Mailing Address - Fax:318-212-5825
Practice Address - Street 1:2518 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3112
Practice Address - Country:US
Practice Address - Phone:318-212-5437
Practice Address - Fax:318-212-5825
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2021112080P0204X
LAMD202111208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine