Provider Demographics
NPI:1932226750
Name:SURYADEVARA, SAMPATH KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:SAMPATH
Middle Name:KUMAR
Last Name:SURYADEVARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 W ROMNEYA DR C
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1817
Mailing Address - Country:US
Mailing Address - Phone:714-520-3000
Mailing Address - Fax:714-520-5742
Practice Address - Street 1:1771 W ROMNEYA DR C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1817
Practice Address - Country:US
Practice Address - Phone:714-520-3000
Practice Address - Fax:714-520-5742
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50601207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty