Provider Demographics
NPI:1679836365
Name:SURESH, TEJAS (MD)
Entity Type:Individual
Prefix:
First Name:TEJAS
Middle Name:
Last Name:SURESH
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 1:3040 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-350-8400
Mailing Address - Fax:703-940-8697
Practice Address - Street 1:7901 LAKE MANASSAS DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3257
Practice Address - Country:US
Practice Address - Phone:703-208-3155
Practice Address - Fax:571-222-2202
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101272283207RH0003X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2I4567OtherMEDICARE PTAN
DCVAC899AOtherMEDICARE PTAN
VA1679836365Medicaid