Healthcare Provider Details

I. General information

NPI: 1235122920
Provider Name (Legal Business Name): SURESH R GUDUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 05/10/2006

III. Provider practice location address

416 PIRKLE FERRY RD STE G100
CUMMING GA
30040-9202
US

IV. Provider business mailing address

416 PIRKLE FERRY RD STE G100
CUMMING GA
30040-9202
US

V. Phone/Fax

Practice location:
  • Phone: 770-205-5720
  • Fax: 770-205-5841
Mailing address:
  • Phone: 770-205-5720
  • Fax: 770-205-5841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042590
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: