Provider Demographics
NPI:1619031572
Name:SUROVEC, DASHA (MD)
Entity Type:Individual
Prefix:
First Name:DASHA
Middle Name:
Last Name:SUROVEC
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 1:1400 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2924
Mailing Address - Country:US
Mailing Address - Phone:707-585-7700
Mailing Address - Fax:707-585-8310
Practice Address - Street 1:1400 MEDICAL CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2924
Practice Address - Country:US
Practice Address - Phone:707-585-7700
Practice Address - Fax:707-585-8310
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 40143208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A48107Medicare UPIN