Provider Demographics
NPI:1790795144
Name:KUMAR, SURENDRA MOHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:MOHAN
Last Name:KUMAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33116 PALMER ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186
Mailing Address - Country:US
Mailing Address - Phone:734-722-0004
Mailing Address - Fax:734-722-0887
Practice Address - Street 1:33116 PALMER ROAD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186
Practice Address - Country:US
Practice Address - Phone:734-722-0004
Practice Address - Fax:734-722-0887
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035001208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1762060Medicaid
MI1762060Medicaid
A77016Medicare UPIN