Provider Demographics
NPI:1477511384
Name:PIDURU, SUSEELA (MD,)
Entity Type:Individual
Prefix:DR
First Name:SUSEELA
Middle Name:
Last Name:PIDURU
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4927 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4813
Mailing Address - Country:US
Mailing Address - Phone:813-960-3919
Mailing Address - Fax:813-960-8414
Practice Address - Street 1:4927 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4813
Practice Address - Country:US
Practice Address - Phone:813-960-3919
Practice Address - Fax:813-960-8414
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME44800OtherMEDICAL LICENSE
FL046849500Medicaid
FLD85404Medicare UPIN