Healthcare Provider Details

I. General information

NPI: 1720106107
Provider Name (Legal Business Name): CHITTAMURU V SURENDRANATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7061 BANDERA RD SUITE 101
SAN ANTONIO TX
78238-1266
US

IV. Provider business mailing address

PO BOX 680935
SAN ANTONIO TX
78268-0935
US

V. Phone/Fax

Practice location:
  • Phone: 210-682-0140
  • Fax: 210-682-3238
Mailing address:
  • Phone: 210-682-0140
  • Fax: 210-682-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberK4257
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberK4257
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: