Healthcare Provider Details

I. General information

NPI: 1356348346
Provider Name (Legal Business Name): DAMODHAR PATTABIRAMAN SURESH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3439
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-287-3045
  • Fax: 859-578-3800
Mailing address:
  • Phone: 859-331-0774
  • Fax: 859-578-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number37142
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-06-8603-S
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number37142
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number01085789A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: