Provider Demographics
NPI:1881126811
Name:SURESH, NITHIN (MD)
Entity type:Individual
Prefix:DR
First Name:NITHIN
Middle Name:
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 1:505 W LOUIS HENNA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-1702
Mailing Address - Country:US
Mailing Address - Phone:855-481-8375
Mailing Address - Fax:
Practice Address - Street 1:701 E FM 1626 STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6075
Practice Address - Country:US
Practice Address - Phone:855-481-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-43811207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS9233OtherTX LICENSE