Provider Demographics
NPI:1669456539
Name:SURI, MADHAV (MD)
Entity Type:Individual
Prefix:
First Name:MADHAV
Middle Name:
Last Name:SURI
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:PO BOX 25548
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5548
Mailing Address - Country:US
Mailing Address - Phone:559-322-7766
Mailing Address - Fax:559-322-7120
Practice Address - Street 1:7151 N CEDAR AVE
Practice Address - Street 2:STE. 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3389
Practice Address - Country:US
Practice Address - Phone:559-322-7766
Practice Address - Fax:559-322-7120
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51804174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A518040Medicaid
CA00A518041Medicare PIN