Provider Demographics
NPI:1114072980
Name:SUTEDJO, JUWONO (MD)
Entity Type:Individual
Prefix:
First Name:JUWONO
Middle Name:
Last Name:SUTEDJO
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 1:1101 MADISON ST, SUITE 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104
Mailing Address - Country:US
Mailing Address - Phone:206-505-1020
Mailing Address - Fax:
Practice Address - Street 1:141 LYNCH CREEK WAY STE C
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2390
Practice Address - Country:US
Practice Address - Phone:707-790-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21983207R00000X, 207RC0000X
MA228744207R00000X
CAC180691207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine