Healthcare Provider Details

I. General information

NPI: 1851521785
Provider Name (Legal Business Name): VIDYA SURAPANENI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 W DUNLAP AVE SUITE 290
PHOENIX AZ
85021-2737
US

IV. Provider business mailing address

2510 W DUNLAP AVE SUITE 290
PHOENIX AZ
85021-2737
US

V. Phone/Fax

Practice location:
  • Phone: 602-789-0344
  • Fax: 602-789-8389
Mailing address:
  • Phone: 602-789-0344
  • Fax: 602-789-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46178
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: