Provider Demographics
NPI:1013602796
Name:KOSURU, DEEPA
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:KOSURU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2661
Mailing Address - Country:US
Mailing Address - Phone:513-496-8400
Mailing Address - Fax:
Practice Address - Street 1:4301 WEST MARKHAM ST., SLOT 530
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-686-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program