Healthcare Provider Details

I. General information

NPI: 1407352198
Provider Name (Legal Business Name): SURAVI GONGULEE THOMAS MPH, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CRESCENT CT APT 4309
SAN FRANCISCO CA
94134-3338
US

IV. Provider business mailing address

410 E PARKCENTER CIR N
SAN BERNARDINO CA
92408-2869
US

V. Phone/Fax

Practice location:
  • Phone: 415-609-4630
  • Fax:
Mailing address:
  • Phone: 909-403-6950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number173587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: