Provider Demographics
NPI:1366433302
Name:VENNA, SURAJ S (MD)
Entity type:Individual
Prefix:DR
First Name:SURAJ
Middle Name:S
Last Name:VENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8081 INNOVATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4867
Mailing Address - Country:US
Mailing Address - Phone:571-472-4724
Mailing Address - Fax:571-472-0241
Practice Address - Street 1:8081 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-4724
Practice Address - Fax:571-472-0241
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2023-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA218355207N00000X
VA0101255078207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2100550Medicaid
MA2100550Medicaid
I33054Medicare UPIN