Provider Demographics
NPI:1285696021
Name:ARK, SURA P (MD)
Entity type:Individual
Prefix:DR
First Name:SURA
Middle Name:P
Last Name:ARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 W EDINGER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-4309
Mailing Address - Country:US
Mailing Address - Phone:714-641-1610
Mailing Address - Fax:714-641-1146
Practice Address - Street 1:1610 W EDINGER AVE.,#B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-4309
Practice Address - Country:US
Practice Address - Phone:714-641-1610
Practice Address - Fax:714-641-1146
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A308950Medicaid
CA00A308950Medicaid
A84144Medicare UPIN