Provider Demographics
NPI:1437144391
Name:SURANA, GAUTAM C (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:C
Last Name:SURANA
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 1:520 WESTFIELD AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1658
Mailing Address - Country:US
Mailing Address - Phone:908-351-4511
Mailing Address - Fax:
Practice Address - Street 1:520 WESTFIELD AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1658
Practice Address - Country:US
Practice Address - Phone:908-451-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03494800207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1535200Medicaid
NJ1535200Medicaid
NJ452472Medicare ID - Type Unspecified