Provider Demographics
NPI:1295393221
Name:SURYAPRAKASH, SHRUTHI (MD)
Entity Type:Individual
Prefix:MS
First Name:SHRUTHI
Middle Name:
Last Name:SURYAPRAKASH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 BEAUBIEN BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-765-1892
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-765-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2020-03-18
Deactivation Date:2020-01-17
Deactivation Code:
Reactivation Date:2020-03-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program