Healthcare Provider Details

I. General information

NPI: 1548495849
Provider Name (Legal Business Name): SUJITH KURUVILLA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 HIGHWAY 54 W STE 2200
FAYETTEVILLE GA
30214-2110
US

IV. Provider business mailing address

PO BOX 116116
ATLANTA GA
30368-6116
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-0051
  • Fax:
Mailing address:
  • Phone: 605-990-8975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number246463-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number246463-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number85754
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: