Provider Demographics
NPI:1083685937
Name:SHARIAR SOTUDEH MD PC
Entity Type:Organization
Organization Name:SHARIAR SOTUDEH MD PC
Other - Org Name:SHARIAR SOTUDEH MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARIAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTUDEH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:914-667-1620
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-0536
Mailing Address - Country:US
Mailing Address - Phone:914-667-1620
Mailing Address - Fax:914-667-2421
Practice Address - Street 1:153 STEVENS AVE STE 5
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2543
Practice Address - Country:US
Practice Address - Phone:914-667-1620
Practice Address - Fax:914-667-2421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124255174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY297301Medicare PIN