Basic Information
| Provider Information | |||||||||
| NPI: | 1477755270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUGUMARAN | ||||||||
| FirstName: | RADHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5201 HARRY HINES BLVD | ||||||||
| Address2: | HOUSE STAFF & GME | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5201 HARRY HINES BLVD | ||||||||
| Address2: | HOUSE STAFF & GME | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908058 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | BP1-0022453 | 01 | INSTITUTIONAL PERMIT | OTHER |