Provider Demographics
NPI:1417916438
Name:PATIBANDLA, SUJANA K (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUJANA
Middle Name:K
Last Name:PATIBANDLA
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 1:4186 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:330-492-5210
Mailing Address - Fax:330-492-5230
Practice Address - Street 1:4186 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-492-5210
Practice Address - Fax:330-492-5230
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048212P207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0505742Medicaid
OHPA0519602Medicare ID - Type Unspecified
OH0505742Medicaid