Provider Demographics
NPI:1134227739
Name:JOHNKUTTY, SUJA S (MD)
Entity type:Individual
Prefix:
First Name:SUJA
Middle Name:S
Last Name:JOHNKUTTY
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:P.O. BOX 224
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-0224
Mailing Address - Country:US
Mailing Address - Phone:631-385-8558
Mailing Address - Fax:631-385-8010
Practice Address - Street 1:33 WALT WHITMAN ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4276
Practice Address - Country:US
Practice Address - Phone:631-385-8558
Practice Address - Fax:631-385-8010
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01093143A2084N0400X
NY2162852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H38908Medicare UPIN