Provider Demographics
NPI:1336242932
Name:YITTA, SUSEELA DEVI PRASAD (MD)
Entity type:Individual
Prefix:
First Name:SUSEELA DEVI
Middle Name:PRASAD
Last Name:YITTA
Suffix:
Gender:F
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:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75902-1648
Mailing Address - Country:US
Mailing Address - Phone:936-853-8249
Mailing Address - Fax:936-853-8220
Practice Address - Street 1:6844 N US HIGHWAY 69
Practice Address - Street 2:
Practice Address - City:POLLOK
Practice Address - State:TX
Practice Address - Zip Code:75969-4548
Practice Address - Country:US
Practice Address - Phone:936-853-8249
Practice Address - Fax:936-853-8220
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131924208000000X
TXF6178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00663992Medicare ID - Type Unspecified
F10972Medicare UPIN