Healthcare Provider Details

I. General information

NPI: 1043461585
Provider Name (Legal Business Name): SUMA GUDUR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 COTTONWOOD VALLEY CIR S
IRVING TX
75038-6212
US

IV. Provider business mailing address

PO BOX 734538
DALLAS TX
75373-4538
US

V. Phone/Fax

Practice location:
  • Phone: 407-374-3455
  • Fax:
Mailing address:
  • Phone: 407-374-3455
  • Fax: 972-252-3019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME105338
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number70391
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP9361
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: