Provider Demographics
NPI:1710273958
Name:NAYAK, SUSHANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHANTH
Middle Name:
Last Name:NAYAK
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:11000 ROOSEVELT BLVD UNIT 360
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3961
Practice Address - Country:US
Practice Address - Phone:215-677-1475
Practice Address - Fax:215-677-3082
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60662834207Q00000X
PAMD473059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR176345Medicare PIN