Provider Demographics
NPI:1619264363
Name:SURINDRA N. MITRUKA, M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SURINDRA N. MITRUKA, M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MD
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGHETALDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-458-5695
Mailing Address - Street 1:2025 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1575 SOQUEL DR
Practice Address - Street 2:SUITE #C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1709
Practice Address - Country:US
Practice Address - Phone:831-458-6288
Practice Address - Fax:831-477-9026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84058208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty