Provider Demographics
NPI:1922007053
Name:SANUSI, HENDRA AUGUSTINUS (MD)
Entity Type:Individual
Prefix:
First Name:HENDRA
Middle Name:AUGUSTINUS
Last Name:SANUSI
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 1:535 WESTFIELD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1725
Mailing Address - Country:US
Mailing Address - Phone:434-973-4040
Mailing Address - Fax:434-974-1780
Practice Address - Street 1:535 WESTFIELD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1725
Practice Address - Country:US
Practice Address - Phone:434-973-4040
Practice Address - Fax:434-974-1780
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA142898OtherSOUTHERN HEALTH
VA005624665Medicaid
VA230912OtherANTHEM
VA230912OtherANTHEM
VA080005615Medicare PIN