Provider Demographics
NPI:1356504302
Name:JIRASAKULDEJ, SUDA
Entity Type:Individual
Prefix:
First Name:SUDA
Middle Name:
Last Name:JIRASAKULDEJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 168TH ST
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3726
Mailing Address - Country:US
Mailing Address - Phone:212-305-1742
Mailing Address - Fax:
Practice Address - Street 1:710 W 168TH ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3726
Practice Address - Country:US
Practice Address - Phone:212-305-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271391-12084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology