Healthcare Provider Details

I. General information

NPI: 1619264363
Provider Name (Legal Business Name): SURINDRA N. MITRUKA, M.D. A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 SOQUEL DR SUITE #C
SANTA CRUZ CA
95065-1709
US

IV. Provider business mailing address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-6288
  • Fax: 831-477-9026
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG84058
License Number StateCA

VIII. Authorized Official

Name: LAWRENCE DEGHETALDI
Title or Position: CEO/MD
Credential:
Phone: 831-458-5695