Provider Demographics
NPI:1790722296
Name:SUDAKIN, LEONARD B (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:B
Last Name:SUDAKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1135
Mailing Address - Country:US
Mailing Address - Phone:248-352-8200
Mailing Address - Fax:248-356-8255
Practice Address - Street 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1753
Practice Address - Country:US
Practice Address - Phone:248-352-8200
Practice Address - Fax:248-356-8255
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301024731207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630132Medicare PIN