Healthcare Provider Details

I. General information

NPI: 1275840878
Provider Name (Legal Business Name): SUCHET SRIVAMSI SURYADEVARA RAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 MEDICAL CENTER DR
SAN BERNARDINO CA
92411-1217
US

IV. Provider business mailing address

2817 WAGON TRAIN LN
DIAMOND BAR CA
91765-3651
US

V. Phone/Fax

Practice location:
  • Phone: 909-887-6333
  • Fax:
Mailing address:
  • Phone: 520-275-7767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number280209
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC172363
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number280209
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number280209
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: