Provider Demographics
NPI:1548291750
Name:SUREKA, AMOD O (MD)
Entity type:Individual
Prefix:
First Name:AMOD
Middle Name:O
Last Name:SUREKA
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 1:2675 N DECATUR RD STE 110
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6130
Mailing Address - Country:US
Mailing Address - Phone:770-979-8080
Mailing Address - Fax:770-979-8099
Practice Address - Street 1:2675 N DECATUR RD STE 110
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6130
Practice Address - Country:US
Practice Address - Phone:770-979-8080
Practice Address - Fax:770-979-8099
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA077948208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107639Medicaid
IL036107639Medicaid
IL1291050001Medicare NSC