Healthcare Provider Details

I. General information

NPI: 1477511384
Provider Name (Legal Business Name): SUSEELA PIDURU M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4927 VAN DYKE RD
LUTZ FL
33558-4813
US

IV. Provider business mailing address

4927 VAN DYKE RD
LUTZ FL
33558-4813
US

V. Phone/Fax

Practice location:
  • Phone: 813-960-3919
  • Fax: 813-960-8414
Mailing address:
  • Phone: 813-960-3919
  • Fax: 813-960-8414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME44800
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: