Provider Demographics
NPI:1497812507
Name:GEORGIE, SUJA (MD)
Entity Type:Individual
Prefix:
First Name:SUJA
Middle Name:
Last Name:GEORGIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUJA
Other - Middle Name:
Other - Last Name:SEBASTIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10200 PARKWOOD DR
Mailing Address - Street 2:#3
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-1479
Mailing Address - Country:US
Mailing Address - Phone:408-216-0297
Mailing Address - Fax:
Practice Address - Street 1:10200 PARKWOOD DR
Practice Address - Street 2:#3
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-1479
Practice Address - Country:US
Practice Address - Phone:408-216-0297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043376207R00000X
CAA 101405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0A1014050OtherMEDI- CAL
I 41215Medicare UPIN
0A1014050Medicare PIN