Provider Demographics
NPI:1861590382
Name:MITRUKA, SURINDRA N (MD)
Entity type:Individual
Prefix:
First Name:SURINDRA
Middle Name:N
Last Name:MITRUKA
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 1:2025 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:831-458-6603
Mailing Address - Fax:831-458-6293
Practice Address - Street 1:1575 SOQUEL DR
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1700
Practice Address - Country:US
Practice Address - Phone:831-458-6288
Practice Address - Fax:831-477-9026
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84058208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G840580Medicaid
F67635Medicare UPIN
00G840580Medicare ID - Type Unspecified