Provider Demographics
NPI:1407352198
Name:THOMAS, SURAVI GONGULEE (MPH, MD)
Entity Type:Individual
Prefix:
First Name:SURAVI
Middle Name:GONGULEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MPH, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E PARKCENTER CIR N
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2869
Mailing Address - Country:US
Mailing Address - Phone:909-403-6950
Mailing Address - Fax:
Practice Address - Street 1:401 CRESCENT CT APT 4309
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-3338
Practice Address - Country:US
Practice Address - Phone:415-609-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA173587207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program