Healthcare Provider Details

I. General information

NPI: 1437144391
Provider Name (Legal Business Name): GAUTAM C SURANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 WESTFIELD AVE SUITE 305
ELIZABETH NJ
07208-1658
US

IV. Provider business mailing address

520 WESTFIELD AVE SUITE 305
ELIZABETH NJ
07208-1658
US

V. Phone/Fax

Practice location:
  • Phone: 908-451-3511
  • Fax:
Mailing address:
  • Phone: 908-351-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA03494800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA03494800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: