Provider Demographics
NPI:1679567606
Name:SODHI, SUDEEP S (MD)
Entity Type:Individual
Prefix:
First Name:SUDEEP
Middle Name:S
Last Name:SODHI
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 1:1550 MIDWAY PL
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1165
Mailing Address - Country:US
Mailing Address - Phone:920-727-8100
Mailing Address - Fax:
Practice Address - Street 1:1550 MIDWAY PL
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1165
Practice Address - Country:US
Practice Address - Phone:920-727-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42404207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33333400Medicaid
WI0380 71018Medicare PIN
H22052Medicare UPIN
WI0363 45300Medicare PIN