Provider Demographics
NPI:1982730636
Name:SUDA, RUSSELL RAYMOND SR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:RAYMOND
Last Name:SUDA
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MOORESVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-0304
Mailing Address - Country:US
Mailing Address - Phone:704-920-1000
Mailing Address - Fax:704-920-1002
Practice Address - Street 1:300 MOORESVILLE RD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-0304
Practice Address - Country:US
Practice Address - Phone:704-920-1000
Practice Address - Fax:704-934-4270
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301416207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135TUMedicaid
NC135TUOtherBCBS ID#
NC89135TUMedicaid
NC2021604AMedicare ID - Type Unspecified