Provider Demographics
NPI:1982658548
Name:DASARI, SUSEELA (MD)
Entity Type:Individual
Prefix:
First Name:SUSEELA
Middle Name:
Last Name:DASARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:3641 W 5TH ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-6424
Practice Address - Country:US
Practice Address - Phone:805-985-5505
Practice Address - Fax:805-984-6095
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51082208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050394OtherBLUE CROSS
CARHM18553HMedicaid
CARHM08608FMedicaid
CARHM08609FMedicaid
CAZZT40394FMedicaid
CA951683892OtherOTHER INSURANCE
CA00C510820Medicaid
CA00C510820Medicaid
CA058609Medicare ID - Type UnspecifiedRH MEDICARE
CARHM08608FMedicaid
CAZZT40394FMedicaid