Provider Demographics
NPI:1558892513
Name:KOSARAJU, SUSHMA (STUDENT)
Entity Type:Individual
Prefix:
First Name:SUSHMA
Middle Name:
Last Name:KOSARAJU
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2204
Mailing Address - Country:US
Mailing Address - Phone:717-763-2219
Mailing Address - Fax:717-972-4844
Practice Address - Street 1:503 N 21ST ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2204
Practice Address - Country:US
Practice Address - Phone:717-763-2219
Practice Address - Fax:717-972-4844
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV390200000X
PAMD4737142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program