Provider Demographics
NPI:1851339493
Name:KOSURI, SUBBA RAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBBA RAJU
Middle Name:
Last Name:KOSURI
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 1:9 MEDICAL PKWY
Mailing Address - Street 2:PLAZA 4, SUITE 207
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7858
Mailing Address - Country:US
Mailing Address - Phone:972-488-9656
Mailing Address - Fax:972-488-9636
Practice Address - Street 1:9 MEDICAL PKWY
Practice Address - Street 2:PLAZA 4, SUITE 207
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7858
Practice Address - Country:US
Practice Address - Phone:972-488-9656
Practice Address - Fax:972-488-9636
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6061207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044799706Medicaid
TX8F3076Medicare UPIN