Provider Demographics
NPI:1235122920
Name:GUDUR, SURESH R (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:R
Last Name:GUDUR
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 1:416 PIRKLE FERRY RD
Mailing Address - Street 2:STE G100
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9202
Mailing Address - Country:US
Mailing Address - Phone:770-205-5720
Mailing Address - Fax:770-205-5841
Practice Address - Street 1:416 PIRKLE FERRY RD
Practice Address - Street 2:STE G100
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9202
Practice Address - Country:US
Practice Address - Phone:770-205-5720
Practice Address - Fax:770-205-5841
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2011-08-10
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-05-10
Provider Licenses
StateLicense IDTaxonomies
GA042590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000720277EMedicaid
GA000720277EMedicaid
G80075Medicare UPIN