Healthcare Provider Details

I. General information

NPI: 1164093282
Provider Name (Legal Business Name): MITHIL GOWDA SURESH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

640 S STATE STREET DOVER,
DOVER DE
19901-3007
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-6999
  • Fax:
Mailing address:
  • Phone: 508-651-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC7-0018794
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: