Provider Demographics
NPI:1093525925
Name:SUKALOSKI, MICHAEL JR (RD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SUKALOSKI
Suffix:JR
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2311
Mailing Address - Country:US
Mailing Address - Phone:207-303-2399
Mailing Address - Fax:
Practice Address - Street 1:119 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2311
Practice Address - Country:US
Practice Address - Phone:207-303-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METD2002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered