Provider Demographics
NPI:1538137351
Name:SUWAN, SAKDIDEJ (MD)
Entity Type:Individual
Prefix:
First Name:SAKDIDEJ
Middle Name:
Last Name:SUWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16229-1121
Mailing Address - Country:US
Mailing Address - Phone:724-295-5202
Mailing Address - Fax:724-295-1160
Practice Address - Street 1:419 MARKET ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:PA
Practice Address - Zip Code:16229-1121
Practice Address - Country:US
Practice Address - Phone:724-295-5202
Practice Address - Fax:724-295-1160
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014710Y207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006560810001Medicaid
PA165045OtherBLUE SHEILD
PAB40466Medicare UPIN
PA0006560810001Medicaid