Provider Demographics
NPI:1326538091
Name:SUSARLA, NAMRATA (MD)
Entity Type:Individual
Prefix:
First Name:NAMRATA
Middle Name:
Last Name:SUSARLA
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 1:2805 RIDGEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-8229
Mailing Address - Country:US
Mailing Address - Phone:484-343-7229
Mailing Address - Fax:
Practice Address - Street 1:702 E 34TH ST STE 202
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3921
Practice Address - Country:US
Practice Address - Phone:417-347-2525
Practice Address - Fax:417-347-2552
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021036900207R00000X
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program