Provider Demographics
NPI:1740867175
Name:PONNA SURI, VIMALA MEGHANA (DO)
Entity type:Individual
Prefix:
First Name:VIMALA
Middle Name:MEGHANA
Last Name:PONNA SURI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VIMALA
Other - Middle Name:MEGHANA PONNA
Other - Last Name:SURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:VIMALA MEGHANA PONNA
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-490-1222
Mailing Address - Fax:
Practice Address - Street 1:3200 KEARNEY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2299
Practice Address - Country:US
Practice Address - Phone:510-490-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A20922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine