Provider Demographics
NPI:1821678376
Name:SURUJDIN, RYAN TEMAL
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TEMAL
Last Name:SURUJDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S MAIN ST STE 240
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-5009
Mailing Address - Country:US
Mailing Address - Phone:817-912-8150
Mailing Address - Fax:
Practice Address - Street 1:620 S MAIN ST STE 240
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-5009
Practice Address - Country:US
Practice Address - Phone:817-912-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU8830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program