Provider Demographics
NPI:1689072811
Name:RAZDAN, SUCHITRA
Entity Type:Individual
Prefix:
First Name:SUCHITRA
Middle Name:
Last Name:RAZDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 S BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2209
Mailing Address - Country:US
Mailing Address - Phone:903-597-2068
Mailing Address - Fax:
Practice Address - Street 1:930 S BAXTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2209
Practice Address - Country:US
Practice Address - Phone:903-597-2068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17678235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001025984Medicaid
TX455429Medicare UPIN