Provider Demographics
NPI:1174829782
Name:SUDLEY MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:SUDLEY MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-626-7501
Mailing Address - Street 1:10757 AMBASSADOR DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2522
Mailing Address - Country:US
Mailing Address - Phone:703-626-7501
Mailing Address - Fax:571-379-7468
Practice Address - Street 1:10757 AMBASSADOR DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2522
Practice Address - Country:US
Practice Address - Phone:703-626-7501
Practice Address - Fax:571-379-7468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty