Provider Demographics
NPI:1457572547
Name:KONERU, SUSHMA (MD)
Entity Type:Individual
Prefix:
First Name:SUSHMA
Middle Name:
Last Name:KONERU
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 1:1723 LUCERNE TER STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2916
Mailing Address - Country:US
Mailing Address - Phone:407-738-4200
Mailing Address - Fax:
Practice Address - Street 1:1723 LUCERNE TER STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2916
Practice Address - Country:US
Practice Address - Phone:407-738-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26298207RC0000X
IL125-050062207R00000X
FLME131009207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020180500Medicaid
IA1457572547Medicaid
IAP01372068OtherRR MEDICARE
IL036120390Medicaid
IA1457572547Medicaid
IA719260579Medicare PIN