Healthcare Provider Details

I. General information

NPI: 1073824306
Provider Name (Legal Business Name): SUJAN KUMAR VADAREVU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N 4TH ST
CLINTON IA
52732-2940
US

IV. Provider business mailing address

1410 N 4TH ST
CLINTON IA
52732-2940
US

V. Phone/Fax

Practice location:
  • Phone: 563-244-5555
  • Fax:
Mailing address:
  • Phone: 563-244-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-41937
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-41937
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: