Healthcare Provider Details

I. General information

NPI: 1750406286
Provider Name (Legal Business Name): KRISHNA M SURTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE KAISER PERMANENTE, DEPT OF RADIOLOGY
FONTANA CA
92335-6720
US

IV. Provider business mailing address

65 HUNTER POINT RD
PHILLIPS RANCH CA
91766-4959
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-4321
  • Fax:
Mailing address:
  • Phone: 626-372-4358
  • Fax: 626-372-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA96563
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA96563
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberA96563
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: