Healthcare Provider Details

I. General information

NPI: 1922007053
Provider Name (Legal Business Name): HENDRA AUGUSTINUS SANUSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 WESTFIELD RD SUITE 200
CHARLOTTESVILLE VA
22901-1725
US

IV. Provider business mailing address

535 WESTFIELD RD SUITE 200
CHARLOTTESVILLE VA
22901-1725
US

V. Phone/Fax

Practice location:
  • Phone: 434-973-4040
  • Fax: 434-974-1780
Mailing address:
  • Phone: 434-973-4040
  • Fax: 434-974-1780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101047354
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: