Provider Demographics
NPI:1316967805
Name:SUTHAKAR, PERIN GOMER (MD)
Entity type:Individual
Prefix:
First Name:PERIN
Middle Name:GOMER
Last Name:SUTHAKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PERIN
Other - Middle Name:
Other - Last Name:GOMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1881 COMMERCENTER E
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3456
Mailing Address - Country:US
Mailing Address - Phone:909-533-4756
Mailing Address - Fax:909-533-4756
Practice Address - Street 1:1881 COMMERCENTER E
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3456
Practice Address - Country:US
Practice Address - Phone:909-533-4756
Practice Address - Fax:909-533-4756
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F9018Medicare PIN
CAF 82325Medicare UPIN