Healthcare Provider Details

I. General information

NPI: 1467436519
Provider Name (Legal Business Name): SURENDRA P KHERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 NW SAINT LUCIE WEST BLVD
PORT ST LUCIE FL
34986-1719
US

IV. Provider business mailing address

10050 SW INNOVATION WAY FL 2
PORT ST LUCIE FL
34987-2117
US

V. Phone/Fax

Practice location:
  • Phone: 772-785-5511
  • Fax: 772-785-5531
Mailing address:
  • Phone: 561-629-2488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number037342
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA10684700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number037342
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME155664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: