Provider Demographics
NPI:1295722874
Name:SUTERA, ANGELO B JR (DPM)
Entity type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:B
Last Name:SUTERA
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 N PROVIDENCE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3530
Mailing Address - Country:US
Mailing Address - Phone:610-566-4563
Mailing Address - Fax:610-566-1856
Practice Address - Street 1:280 N PROVIDENCE RD STE 103
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3530
Practice Address - Country:US
Practice Address - Phone:610-566-4563
Practice Address - Fax:610-566-1856
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003658L213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1445475Medicaid
PA1445475Medicaid
PA058453Medicare ID - Type Unspecified