Provider Demographics
NPI:1790721645
Name:GOLI, SUJATHA A (MD)
Entity Type:Individual
Prefix:
First Name:SUJATHA
Middle Name:A
Last Name:GOLI
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 1:2501 JIMMY JOHNSON BLVD STE 406
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2013
Mailing Address - Country:US
Mailing Address - Phone:409-548-4761
Mailing Address - Fax:
Practice Address - Street 1:2501 JIMMY JOHNSON BLVD STE 406
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2013
Practice Address - Country:US
Practice Address - Phone:409-548-4761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1822207RP1001X, 207RC0200X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ1822OtherTEXAS MEDICAL LICENSE
TN3333817Medicaid
TXQ1822OtherTEXAS MEDICAL LICENSE