Provider Demographics
NPI:1790811255
Name:THRASYBULE, SUJA T (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUJA
Middle Name:T
Last Name:THRASYBULE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:9601 PULASKI PARK DR STE 416
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:410-238-7451
Practice Address - Street 1:2511 EDISON HWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213
Practice Address - Country:US
Practice Address - Phone:410-675-4500
Practice Address - Fax:410-675-4556
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2018-08-01
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Provider Licenses
StateLicense IDTaxonomies
MDD0051425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH01916Medicare UPIN