Provider Demographics
NPI:1518968841
Name:SUR, MOUSOOMI M (MD)
Entity Type:Individual
Prefix:MS
First Name:MOUSOOMI
Middle Name:M
Last Name:SUR
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:2083 E HOSPITALITY LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6603
Practice Address - Country:US
Practice Address - Phone:208-333-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000417Medicare PIN