Provider Demographics
NPI:1437297298
Name:VUTHOORI, SURENDER (MD)
Entity Type:Individual
Prefix:
First Name:SURENDER
Middle Name:
Last Name:VUTHOORI
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:PO BOX 168
Mailing Address - Street 2:6353229 PALMS HWY STE A
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252
Mailing Address - Country:US
Mailing Address - Phone:760-366-8491
Mailing Address - Fax:760-346-2471
Practice Address - Street 1:63532 29 PALMS HWY
Practice Address - Street 2:STE A
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252
Practice Address - Country:US
Practice Address - Phone:760-366-8491
Practice Address - Fax:760-346-2471
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33804207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A338041Medicaid
CA00A338040OtherBLUE SHIELD
CA756061629OtherRAILROAD MEDICARE NUMBER
CA00A338040Medicaid
CA953529571OtherBLUE CROSS
CA00A338040OtherBLUE SHIELD
CAZZZ91620ZMedicare ID - Type Unspecified
CA00A338041Medicaid
CA756061629OtherRAILROAD MEDICARE NUMBER
CABQ049Medicare PIN