MEDICARE: SURYA RAJ SUDARSAN DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	5951001629	MI

General Provider Information

NPI Number	:	1467385583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURYA RAJ SUDARSAN DPM

Provider Business Mailing Address
First Line	:	2600 ROBINS WAY
Second Line	:
City	:	OKEMOS
State	:	MI
Zip	:	48864-3380
Country	:	US
Telephone Number	:	517-898-1928
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 SAINT ANTOINE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2153
Country	:	US
Telephone Number	:	517-898-1928
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/16/2026

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