Provider Demographics
NPI:1710987581
Name:SUCHARETZA, BRIAN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
Last Name:SUCHARETZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:515 PARK PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3566
Mailing Address - Country:US
Mailing Address - Phone:574-607-4724
Mailing Address - Fax:574-607-4725
Practice Address - Street 1:515 PARK PLACE
Practice Address - Street 2:SUITE 200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3566
Practice Address - Country:US
Practice Address - Phone:574-607-4724
Practice Address - Fax:574-607-4725
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01042730A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100462420AMedicaid
INE96564Medicare UPIN
IN140630FMedicare ID - Type Unspecified