Provider Demographics
NPI:1710654710
Name:KUSHVAH, SURAJ RAGHURAJ
Entity Type:Individual
Prefix:
First Name:SURAJ
Middle Name:RAGHURAJ
Last Name:KUSHVAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9840 MIRA LEE WAY APT 20212
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4755
Mailing Address - Country:US
Mailing Address - Phone:248-821-1325
Mailing Address - Fax:
Practice Address - Street 1:9840 MIRA LEE WAY APT 20212
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4755
Practice Address - Country:US
Practice Address - Phone:248-821-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist