Provider Demographics
NPI:1356348346
Name:SURESH, DAMODHAR PATTABIRAMAN (MD)
Entity type:Individual
Prefix:DR
First Name:DAMODHAR
Middle Name:PATTABIRAMAN
Last Name:SURESH
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-331-0774
Mailing Address - Fax:859-578-3800
Practice Address - Street 1:711 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3439
Practice Address - Country:US
Practice Address - Phone:859-287-3045
Practice Address - Fax:859-578-3800
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37142207RC0000X, 207RI0011X
OH35-06-8603-S207RC0000X
IN01085789A207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0369016OtherMEDICARE
KY0562616OtherMEDICARE
KY0969497OtherMEDICARE PTAN
KY64962830Medicaid
060067789OtherRAILROAD MEDICARE
OH611300608064OtherCARESOURCE
OH2000420Medicaid
OHP00893681OtherRAILROAD MEDICARE
KYP00922859OtherRAIL ROAD MEDICARE
KY50024711OtherPASSPORT MEDICAID
KY0369209OtherMEDICARE
OH0816359Medicare PIN
KYP400019610Medicare PIN
KY0562616Medicare PIN
KYP00922859OtherRAIL ROAD MEDICARE
OHP00893681OtherRAILROAD MEDICARE
KY0369016OtherMEDICARE
OHSU4157244Medicare PIN
OH0816355Medicare PIN
KY0369209Medicare PIN
KY0369016Medicare PIN