Provider Demographics
NPI:1467401596
Name:SURAPANENI, PURUSHOTHAM N (MD)
Entity Type:Individual
Prefix:DR
First Name:PURUSHOTHAM
Middle Name:N
Last Name:SURAPANENI
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 1:77 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1357
Mailing Address - Country:US
Mailing Address - Phone:201-818-0960
Mailing Address - Fax:201-825-9537
Practice Address - Street 1:27 S FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2550
Practice Address - Country:US
Practice Address - Phone:201-818-0960
Practice Address - Fax:201-825-9537
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8517100Medicaid
NJ043557Medicare ID - Type Unspecified
NJ8517100Medicaid