Healthcare Provider Details

I. General information

NPI: 1285954206
Provider Name (Legal Business Name): SASIDHAR SOMURI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 04/24/2021
Certification Date: 04/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N 4TH ST
CLINTON IA
52732-2940
US

IV. Provider business mailing address

5546 WILLMEYER DR
BETTENDORF IA
52722-2461
US

V. Phone/Fax

Practice location:
  • Phone: 563-244-5555
  • Fax:
Mailing address:
  • Phone: 347-463-0757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036125883
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036125883
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: