Provider Demographics
NPI:1821412065
Name:SUAZO, MARLO
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:SUAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BAYARD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3147
Mailing Address - Country:US
Mailing Address - Phone:631-912-7476
Mailing Address - Fax:
Practice Address - Street 1:11 BAYARD ST
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-3147
Practice Address - Country:US
Practice Address - Phone:631-912-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile