Provider Demographics
NPI:1306333174
Name:SUEZAKI, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:SUEZAKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MONTCLAIR AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1761
Mailing Address - Country:US
Mailing Address - Phone:408-251-0547
Mailing Address - Fax:
Practice Address - Street 1:250 MONTCLAIR AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116
Practice Address - Country:US
Practice Address - Phone:408-251-0547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1026321223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice