Provider Demographics
NPI:1770652299
Name:DHILLON, SURISHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SURISHAM
Middle Name:
Last Name:DHILLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23928 LYONS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2452
Mailing Address - Country:US
Mailing Address - Phone:661-222-2326
Mailing Address - Fax:661-222-9444
Practice Address - Street 1:23928 LYONS AVE STE 102
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2452
Practice Address - Country:US
Practice Address - Phone:661-222-2326
Practice Address - Fax:661-222-9444
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51651174400000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51651OtherLICENSE NUMBER
CA6507231OtherMEDICAL
CABD4511350OtherDEA NUMBER
CABD4511350OtherDEA NUMBER
CAG63218Medicare UPIN