Provider Demographics
NPI:1093704686
Name:SUDELA, THOMAS STEPHEN (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:STEPHEN
Last Name:SUDELA
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 1:2504 RIDGE ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087
Mailing Address - Country:US
Mailing Address - Phone:972-722-0404
Mailing Address - Fax:972-722-7082
Practice Address - Street 1:2504 RIDGE ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087
Practice Address - Country:US
Practice Address - Phone:972-722-0404
Practice Address - Fax:972-722-7082
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6639207V00000X
TXB6639207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114204402Medicaid
TXE6639OtherMEDICAL LICENSE
TXE6639OtherMEDICAL LICENSE
TXB26767Medicare UPIN