Provider Demographics
NPI:1245413673
Name:KONESWARAN, SURESH A (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:A
Last Name:KONESWARAN
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 1:518 S VAN BUREN RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5033
Mailing Address - Country:US
Mailing Address - Phone:336-623-7881
Mailing Address - Fax:336-623-5457
Practice Address - Street 1:518 S VAN BUREN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5033
Practice Address - Country:US
Practice Address - Phone:336-623-7881
Practice Address - Fax:336-623-5457
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00260207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC200957430Medicaid