Provider Demographics
NPI:1619043874
Name:SUREKHA S VETSA MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SUREKHA S VETSA MD A MEDICAL CORPORATION
Other - Org Name:SUREKHA S VETSA MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO OF SUREKHA S VETSA MD A MEDICAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SUREKHA
Authorized Official - Middle Name:SANTOSHKUMAR
Authorized Official - Last Name:VETSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-888-7556
Mailing Address - Street 1:1351 SELO DRIVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-4411
Mailing Address - Country:US
Mailing Address - Phone:650-888-7556
Mailing Address - Fax:408-733-0777
Practice Address - Street 1:150 N JACKSON AVE STE 105C
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1908
Practice Address - Country:US
Practice Address - Phone:650-888-1917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90010207P00000X, 207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04261ZMedicare ID - Type UnspecifiedGERIATRIC PRACTICE