Provider Demographics
NPI:1790097608
Name:BOORLA, SUSHRUTI (DO)
Entity Type:Individual
Prefix:
First Name:SUSHRUTI
Middle Name:
Last Name:BOORLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6957 W PLANO PKWY STE 1000
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-1621
Mailing Address - Country:US
Mailing Address - Phone:972-939-8294
Mailing Address - Fax:214-731-0240
Practice Address - Street 1:6957 W PLANO PKWY STE 1000
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-1621
Practice Address - Country:US
Practice Address - Phone:972-939-8294
Practice Address - Fax:214-731-0240
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7054207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216678701Medicaid
TX216678702Medicaid
TX216678703Medicaid
TX216678705Medicaid
TXTXB122108Medicare PIN
TX216678702Medicaid
TX216678703Medicaid
TX216678701Medicaid