Provider Demographics
NPI:1992769137
Name:DUTTA, SURESH V (MD)
Entity type:Individual
Prefix:DR
First Name:SURESH
Middle Name:V
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1010 NW LOOP 410
Mailing Address - Street 2:SUITE 100D
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2220
Mailing Address - Country:US
Mailing Address - Phone:210-308-9999
Mailing Address - Fax:210-308-6262
Practice Address - Street 1:1010 NW LOOP 410
Practice Address - Street 2:SUITE 100D
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2220
Practice Address - Country:US
Practice Address - Phone:210-308-9999
Practice Address - Fax:210-308-6262
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL10242085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0449803-02Medicaid
TX0449803-02Medicaid