Provider Demographics
NPI:1558066308
Name:SURJANTO, KEZIA IVANKA (MD)
Entity Type:Individual
Prefix:
First Name:KEZIA
Middle Name:IVANKA
Last Name:SURJANTO
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 1:1430 TULANE AVE # 8050
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-7809
Mailing Address - Fax:504-988-3971
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-7809
Practice Address - Fax:504-988-3971
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program