Provider Demographics
NPI:1124020136
Name:SUDA, RICHARD W (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:SUDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 530
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-244-4374
Mailing Address - Fax:818-244-0633
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 530
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-244-4374
Practice Address - Fax:818-244-0633
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG53084208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086630Medicaid
CAE89868Medicare UPIN
CAGR0086630Medicaid