Healthcare Provider Details

I. General information

NPI: 1922075035
Provider Name (Legal Business Name): SURESH KUMAR DONEPUDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8921 MANSFIELD RD
SHREVEPORT LA
71118-2144
US

IV. Provider business mailing address

8921 MANSFIELD RD
SHREVEPORT LA
71118-2144
US

V. Phone/Fax

Practice location:
  • Phone: 318-688-5416
  • Fax: 318-688-5823
Mailing address:
  • Phone: 318-688-5416
  • Fax: 318-688-5823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number017479
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: