Provider Demographics
NPI:1922008382
Name:SURY, MANI N (MD)
Entity type:Individual
Prefix:DR
First Name:MANI
Middle Name:N
Last Name:SURY
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 1:4204 MERIDIAN ST
Mailing Address - Street 2:STE. 105
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-5545
Mailing Address - Country:US
Mailing Address - Phone:360-733-4555
Mailing Address - Fax:360-752-1407
Practice Address - Street 1:4204 MERIDIAN ST
Practice Address - Street 2:STE. 105
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5545
Practice Address - Country:US
Practice Address - Phone:360-733-4555
Practice Address - Fax:360-752-1407
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2021-04-30
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
AZ50879207R00000X
WAMD00035953207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1119957Medicaid
WAA24873Medicare UPIN
WA1119957Medicaid