Healthcare Provider Details

I. General information

NPI: 1528346251
Provider Name (Legal Business Name): SUPRAJA YETURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 I 49 S SERVICE RD SUITE 200
OPELOUSAS LA
70570-0775
US

IV. Provider business mailing address

2390 W. CONGRESS ST.
LAFAYETTE LA
70506
US

V. Phone/Fax

Practice location:
  • Phone: 337-594-3980
  • Fax:
Mailing address:
  • Phone: 337-261-6759
  • Fax: 337-261-6795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD301713
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: