Healthcare Provider Details

I. General information

NPI: 1912265760
Provider Name (Legal Business Name): SUSHITHA SURENDRAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S STE 500
RENTON WA
98055-5782
US

IV. Provider business mailing address

315 N SAN SABA STE 1135
SAN ANTONIO TX
78207-3255
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3482
  • Fax: 425-690-9082
Mailing address:
  • Phone: 210-704-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberU5312
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number24976
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberU5312
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD61232884
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: