Provider Demographics
NPI:1407053796
Name:SUDAR, MARTIN EDWARD (LPTA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:EDWARD
Last Name:SUDAR
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 BOTTICELLI ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1303
Mailing Address - Country:US
Mailing Address - Phone:503-699-8128
Mailing Address - Fax:
Practice Address - Street 1:3814 BOTTICELLI ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-1303
Practice Address - Country:US
Practice Address - Phone:503-699-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7928225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant