Provider Demographics
NPI:1619076866
Name:BENNURI, SUDHA SAGAR (MD)
Entity Type:Individual
Prefix:MR
First Name:SUDHA
Middle Name:SAGAR
Last Name:BENNURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 20TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3832
Mailing Address - Country:US
Mailing Address - Phone:205-333-8900
Mailing Address - Fax:205-333-6090
Practice Address - Street 1:2701 20TH AVENUE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3832
Practice Address - Country:US
Practice Address - Phone:205-333-5900
Practice Address - Fax:205-333-6090
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009978025Medicaid
AL009978025Medicaid