Provider Demographics
NPI:1851345300
Name:SPUDICH, SERENA SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:SUSAN
Last Name:SPUDICH
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:PO BOX 208018
Mailing Address - Street 2:DEPARTMENT OF NEUROLOGY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8018
Mailing Address - Country:US
Mailing Address - Phone:203-737-1969
Mailing Address - Fax:
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:DEPARTMENT OF NEUROLOGY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-737-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA824512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A824510Medicaid
CA00A824510Medicare ID - Type Unspecified
CA00A824510Medicaid