Provider Demographics
NPI:1063611234
Name:KOMPELLA, SUVARCHALA SURYA RAMA
Entity type:Individual
Prefix:
First Name:SUVARCHALA
Middle Name:SURYA RAMA
Last Name:KOMPELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 MATTOS DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-6719
Mailing Address - Country:US
Mailing Address - Phone:408-368-7660
Mailing Address - Fax:
Practice Address - Street 1:220 E HACIENDA AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-6617
Practice Address - Country:US
Practice Address - Phone:408-368-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA101614207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA101614OtherMED LICENSE