Provider Demographics
NPI:1255317004
Name:MUSUNURI, MAHESHWAR R (MD)
Entity Type:Individual
Prefix:
First Name:MAHESHWAR
Middle Name:R
Last Name:MUSUNURI
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 1:3000 GUERNSEY ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906-1540
Mailing Address - Country:US
Mailing Address - Phone:740-676-4623
Mailing Address - Fax:740-671-6333
Practice Address - Street 1:3000 GUERNSEY ST
Practice Address - Street 2:SUITE 16
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-1540
Practice Address - Country:US
Practice Address - Phone:740-676-4623
Practice Address - Fax:740-671-6333
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070697M207R00000X
WV18659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0079628000Medicaid
OH0381368Medicaid
OH0381368Medicaid
G40049Medicare UPIN
WV0079628000Medicaid