Provider Demographics
NPI:1093966269
Name:SUOZZI, BRENT A (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:SUOZZI
Suffix:
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 1:8051 S EMERSON AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8633
Mailing Address - Country:US
Mailing Address - Phone:317-790-3355
Mailing Address - Fax:317-790-3002
Practice Address - Street 1:8051 S EMERSON AVE STE 400
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8633
Practice Address - Country:US
Practice Address - Phone:317-790-3355
Practice Address - Fax:317-790-3002
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072583A207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01072583AOtherLICENSE
IN201190860Medicaid
IN201190860Medicaid
IN000000828518OtherANTHEM PIN NUMBER
IN1205916830OtherGREENWOOD DME
IN200288740OtherGROUP MEDICAID NUMBER
IN677730006Medicare PIN