Provider Demographics
NPI:1528024239
Name:VAJRAKARUR, SUSEELA
Entity Type:Individual
Prefix:
First Name:SUSEELA
Middle Name:
Last Name:VAJRAKARUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-5027
Mailing Address - Country:US
Mailing Address - Phone:912-356-2011
Mailing Address - Fax:912-351-3538
Practice Address - Street 1:1915 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-5027
Practice Address - Country:US
Practice Address - Phone:912-356-2011
Practice Address - Fax:912-351-3538
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028662208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA028662OtherLICENSE
GAC45519Medicare UPIN
GA37BDBXMMedicare ID - Type Unspecified