Provider Demographics
NPI:1720199201
Name:SUCHYTA, MARY R (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:SUCHYTA
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 1:1718 HERBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1830
Mailing Address - Country:US
Mailing Address - Phone:801-884-8297
Mailing Address - Fax:
Practice Address - Street 1:9493 S 700 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3459
Practice Address - Country:US
Practice Address - Phone:801-576-0176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT871766381204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005587628Medicare PIN
UT005548801Medicare PIN
UT005569129Medicare PIN
UT006985026Medicare PIN
UT005583346Medicare PIN
UT005586729Medicare PIN