Provider Demographics
NPI:1467433862
Name:SUITE, DEREK HUDSON (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:HUDSON
Last Name:SUITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1136 NEILL AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2801
Mailing Address - Country:US
Mailing Address - Phone:718-518-7600
Mailing Address - Fax:718-518-7647
Practice Address - Street 1:1136 NEILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1328
Practice Address - Country:US
Practice Address - Phone:718-518-7600
Practice Address - Fax:718-518-7647
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY198909-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02501820Medicaid
NYWEE901Medicare ID - Type Unspecified