Provider Demographics
NPI:1215905864
Name:SUDO, MICHELLE K (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:K
Last Name:SUDO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1102 HIGHWAY 315 BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6943
Mailing Address - Country:US
Mailing Address - Phone:570-235-1470
Mailing Address - Fax:570-550-9256
Practice Address - Street 1:1102 HIGHWAY 315 BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6943
Practice Address - Country:US
Practice Address - Phone:570-235-1470
Practice Address - Fax:570-550-9356
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009616L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001677040Medicaid
PA001677040Medicaid