Healthcare Provider Details

I. General information

NPI: 1497511448
Provider Name (Legal Business Name): SUSHMA INDUKURI MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W EATON AVE STE B
TRACY CA
95376-3454
US

IV. Provider business mailing address

120 W LADD DR
TRACY CA
95391-1363
US

V. Phone/Fax

Practice location:
  • Phone: 209-445-9427
  • Fax:
Mailing address:
  • Phone: 209-445-9427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSHMA INDUKURI
Title or Position: DOCTOR
Credential:
Phone: 209-445-9427