Healthcare Provider Details

I. General information

NPI: 1700873262
Provider Name (Legal Business Name): HARI KRISHNA SUSARLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 FM 1960 RD W SUITE 105
HOUSTON TX
77090-3423
US

IV. Provider business mailing address

11511 SHADOW CREEK PARKWAY HR/CREDENTIALING SERVICES
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 281-586-3888
  • Fax: 281-440-2020
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL7205
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL7205
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: