Provider Demographics
NPI:1043517790
Name:SUDARA PT PC
Entity Type:Organization
Organization Name:SUDARA PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T.
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ- HERRANZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-236-7707
Mailing Address - Street 1:5327 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1523
Mailing Address - Country:US
Mailing Address - Phone:718-236-7707
Mailing Address - Fax:718-236-3300
Practice Address - Street 1:5327 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1523
Practice Address - Country:US
Practice Address - Phone:718-236-7707
Practice Address - Fax:718-236-3300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030017-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy