Provider Demographics
NPI:1659562775
Name:SUSARLA, SRINIVAS M (MD, DMD)
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:M
Last Name:SUSARLA
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 SAND POINT WAY NE
Mailing Address - Street 2:SEATTLE CHILDREN'S HOSPITAL
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:SEATTLE CHILDREN'S HOSPITAL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADF606680281223S0112X
WAMD606280002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery