Provider Demographics
NPI:1841826377
Name:SUDBROOK, MICHAEL (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SUDBROOK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5923 BOGIE WAY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3040
Mailing Address - Country:US
Mailing Address - Phone:832-528-5533
Mailing Address - Fax:
Practice Address - Street 1:3320 BROADWAY ST STE 108
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-4376
Practice Address - Country:US
Practice Address - Phone:281-809-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21131412081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine