Provider Demographics
NPI:1245385913
Name:SUDAK, DONNA M (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:SUDAK
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 1:245 N 15TH ST
Mailing Address - Street 2:MAIL STOP 403
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1101
Mailing Address - Country:US
Mailing Address - Phone:215-873-0245
Mailing Address - Fax:215-762-4259
Practice Address - Street 1:245 N 15TH ST
Practice Address - Street 2:MAIL STOP 403
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1101
Practice Address - Country:US
Practice Address - Phone:215-873-0245
Practice Address - Fax:215-762-4259
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053312L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103543Medicare ID - Type Unspecified
PAA05179Medicare UPIN