Provider Demographics
NPI:1629446208
Name:GURUSAMY, DEEPA (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:
Last Name:GURUSAMY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 HAMILL RD STE 214
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5152
Mailing Address - Country:US
Mailing Address - Phone:423-778-9030
Mailing Address - Fax:423-778-9031
Practice Address - Street 1:1724 HAMILL RD STE 214
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-5152
Practice Address - Country:US
Practice Address - Phone:423-778-9030
Practice Address - Fax:423-778-9031
Is Sole Proprietor?:No
Enumeration Date:2015-09-13
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN57780207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN57780OtherTENNESSEE BOARD OF MEDICAL EXAMINERS