Provider Demographics
NPI:1639168636
Name:MOTTA, SUNIL (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNIL
Middle Name:
Last Name:MOTTA
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 1:2405 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-6214
Mailing Address - Country:US
Mailing Address - Phone:315-798-9788
Mailing Address - Fax:315-798-9766
Practice Address - Street 1:2209 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5930
Practice Address - Country:US
Practice Address - Phone:315-798-9788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205347-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
11316374OtherCAQH
NY050056428OtherPALMETTO
00040557202OtherUNIVERA
NY01753704Medicaid
NY00931237Medicaid
NY958081OtherMUP
40426014281OtherFIDELIS
00040557202OtherUNIVERA
11316374OtherCAQH
54602AMedicare ID - Type UnspecifiedGROUP