Provider Demographics
NPI:1487792057
Name:SUBRAMANIAN, SUJATA (MD)
Entity type:Individual
Prefix:
First Name:SUJATA
Middle Name:
Last Name:SUBRAMANIAN
Suffix:
Gender:F
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0002
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-126866208G00000X
OH35138048208G00000X
PAMD425377208G00000X
TXS6748208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-126866OtherSTATE LICENSE