Healthcare Provider Details

I. General information

NPI: 1063919983
Provider Name (Legal Business Name): SOORAJ JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 09/22/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-8025
  • Fax: 540-853-0511
Mailing address:
  • Phone: 540-224-5715
  • Fax: 540-224-5684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101274548
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD.38998
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: