Provider Demographics
NPI:1700873262
Name:SUSARLA, HARI KRISHNA (MD)
Entity type:Individual
Prefix:DR
First Name:HARI
Middle Name:KRISHNA
Last Name:SUSARLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PARKWAY HR/CREDENTIALING SERVICES
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:837 FM 1960 RD W
Practice Address - Street 2:SUITE 105
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3423
Practice Address - Country:US
Practice Address - Phone:281-586-3888
Practice Address - Fax:281-440-2020
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7205208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1626293-01Medicaid
TX1626293-01Medicaid
TXH96193Medicare UPIN
TX8F4912Medicare ID - Type UnspecifiedFORT BEND CTY INDV PTAN#
TX8F4913Medicare ID - Type UnspecifiedHARRIS COUNTY INDV PTAN #