Provider Demographics
NPI:1427034727
Name:MAXIMIN, SURESH T (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:T
Last Name:MAXIMIN
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 1:8631 FAUNTLEROY WAY SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98136-2439
Mailing Address - Country:US
Mailing Address - Phone:206-788-7998
Mailing Address - Fax:
Practice Address - Street 1:8631 FAUNTLEROY WAY SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-2439
Practice Address - Country:US
Practice Address - Phone:206-788-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1946482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015541280Medicaid
NY01541280Medicaid
NY01541280Medicaid
NY66J021Medicare ID - Type Unspecified
NY015541280Medicaid