Provider Demographics
NPI:1700098852
Name:SUJA JOHNKUTTY, M.D., P.L.L.C.
Entity Type:Organization
Organization Name:SUJA JOHNKUTTY, M.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUJA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNKUTTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-385-8558
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X
NY2162852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WWS671Medicare PIN
NYG400045122Medicare PIN