Provider Demographics
NPI:1891074803
Name:SURABHI, PRANITH (MD)
Entity Type:Individual
Prefix:DR
First Name:PRANITH
Middle Name:
Last Name:SURABHI
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 1:3135 W BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3359
Mailing Address - Country:US
Mailing Address - Phone:712-242-2040
Mailing Address - Fax:712-325-2445
Practice Address - Street 1:3135 W BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3359
Practice Address - Country:US
Practice Address - Phone:712-242-2040
Practice Address - Fax:712-325-2445
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA41854207Q00000X
NE28025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0414530142Medicare NSC