Provider Demographics
NPI:1225272248
Name:DUDYCZ-SULICZ, KATARZYNA IRENA (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATARZYNA
Middle Name:IRENA
Last Name:DUDYCZ-SULICZ
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-797-1251
Mailing Address - Fax:607-729-4393
Practice Address - Street 1:4417 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-797-1251
Practice Address - Fax:607-729-4393
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42542208000000X
NY273928208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03873067Medicaid
NYJ400151043Medicare PIN