Provider Demographics
NPI:1417940909
Name:SURAKANTI, MAHENDER REDDY (MD)
Entity Type:Individual
Prefix:
First Name:MAHENDER
Middle Name:REDDY
Last Name:SURAKANTI
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 1:10214 CHESTNUT PLAZA DR # 306
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8970
Mailing Address - Country:US
Mailing Address - Phone:260-203-4188
Mailing Address - Fax:260-203-5136
Practice Address - Street 1:7806 W JEFFERSON BLVD STE C
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-203-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057700A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200442540AMedicaid
INH58337Medicare UPIN
IN207300AMedicare ID - Type UnspecifiedPROVIDER ID