Provider Demographics
NPI:1407054026
Name:RAYTHATHA, SURENDRA HARIDAS (MD)
Entity type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:HARIDAS
Last Name:RAYTHATHA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18980 W MEMORIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-4559
Mailing Address - Country:US
Mailing Address - Phone:832-644-8930
Mailing Address - Fax:
Practice Address - Street 1:7821 FM 1960 RD E
Practice Address - Street 2:
Practice Address - City:ATASCOCITA
Practice Address - State:TX
Practice Address - Zip Code:77346-2205
Practice Address - Country:US
Practice Address - Phone:832-644-8930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISR040618207Q00000X
TXQ1717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0790012OtherBLUE CROSS BLUE SHIELD
MI2763572Medicaid
MI2763572Medicaid
MIA73208Medicare UPIN