Provider Demographics
NPI:1285658195
Name:PARK-IDLER, SUJI (MD)
Entity type:Individual
Prefix:
First Name:SUJI
Middle Name:
Last Name:PARK-IDLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUJI
Other - Middle Name:
Other - Last Name:WON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8470 FALLS OF NEUSE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3500
Mailing Address - Country:US
Mailing Address - Phone:919-322-5555
Mailing Address - Fax:
Practice Address - Street 1:8470 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-322-5555
Practice Address - Fax:984-255-0908
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89376207R00000X
NC2008-01919208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89376OtherMEDICAL LICENSE
NC2008-01919OtherNORTH CAROLINA STATE MEDICAL LICENSE
NC2008-01919OtherNORTH CAROLINA STATE MEDICAL LICENSE
I156943Medicare UPIN