MEDICARE: SURAJ RAGHURAJ KUSHVAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40101	CA

General Provider Information

NPI Number	:	1710654710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURAJ RAGHURAJ KUSHVAH

Provider Business Mailing Address
First Line	:	9840 MIRA LEE WAY APT 20212
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4755
Country	:	US
Telephone Number	:	248-821-1325
Fax Number	:

Provider Business Practice Location Address
First Line	:	9840 MIRA LEE WAY APT 20212
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4755
Country	:	US
Telephone Number	:	248-821-1325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2021
Last Update Date	:	08/26/2021

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