Provider Demographics
NPI:1861408007
Name:SUKUMARAN, SURAJ (MD)
Entity type:Individual
Prefix:DR
First Name:SURAJ
Middle Name:
Last Name:SUKUMARAN
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 1:1067 PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30434-1558
Mailing Address - Country:US
Mailing Address - Phone:478-625-7000
Mailing Address - Fax:478-625-8907
Practice Address - Street 1:1067 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-1558
Practice Address - Country:US
Practice Address - Phone:478-625-7000
Practice Address - Fax:478-625-8907
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000800357AMedicaid
GA000800357AMedicaid