=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275840878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUCHET SRIVAMSI SURYADEVARA RAO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2010
-----------------------------------------------------
Last Update Date | 04/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1805 MEDICAL CENTER DR
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92411-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-887-6333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2817 WAGON TRAIN LN
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-3651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-275-7767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | C172363
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084F0202X
-----------------------------------------------------
Taxonomy Name | Forensic Psychiatry Physician
-----------------------------------------------------
License Number | 280209
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 280209
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 280209
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------