Provider Demographics
NPI:1568515161
Name:DE, SULAGNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SULAGNA
Middle Name:
Last Name:DE
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:ROUTE 611 STROUD BLDG SUITE 100B
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-9317
Mailing Address - Country:US
Mailing Address - Phone:570-420-5435
Mailing Address - Fax:570-420-5437
Practice Address - Street 1:ROUTE 611 STROUD BLDG SUITE 100B
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-9317
Practice Address - Country:US
Practice Address - Phone:570-420-5435
Practice Address - Fax:570-420-5437
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD066364L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017538940005Medicaid
PA0017538940005Medicaid
PAG95032Medicare UPIN