Provider Demographics
NPI:1760443816
Name:KURUVILLA, VARUGHESE (MD)
Entity type:Individual
Prefix:DR
First Name:VARUGHESE
Middle Name:
Last Name:KURUVILLA
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 1:5401 OLD COURT RD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:5400 OLD COURT RD
Practice Address - Street 2:SUITE 208
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:410-561-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD23628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD20039228OtherR/R MEDICARE PROVIDER #
MDCN6601OtherR/R MEDICARE GROUP #
MDB66825Medicare UPIN