Healthcare Provider Details

I. General information

NPI: 1619043874
Provider Name (Legal Business Name): SUREKHA S VETSA MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N JACKSON AVE STE 105C
SAN JOSE CA
95116-1908
US

IV. Provider business mailing address

1351 SELO DRIVE
SUNNYVALE CA
94087-4411
US

V. Phone/Fax

Practice location:
  • Phone: 650-888-1917
  • Fax:
Mailing address:
  • Phone: 650-888-7556
  • Fax: 408-733-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA90010
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA90010
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA90010
License Number StateCA

VIII. Authorized Official

Name: DR. SUREKHA SANTOSHKUMAR VETSA
Title or Position: CEO OF SUREKHA S VETSA MD A MEDICAL
Credential: MD
Phone: 650-888-7556