Provider Demographics
NPI:1477782910
Name:HOSURU, SURESH BABU (MD,)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:BABU
Last Name:HOSURU
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:2505 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2839
Practice Address - Country:US
Practice Address - Phone:209-957-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070791A208M00000X, 207R00000X
CAA137688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01168490OtherRAILROAD MEDICARE
IN201064230Medicaid
IN202020011Medicare PIN
INM400071020Medicare PIN