Provider Demographics
NPI:1427236835
Name:SUDITU, BRUNO MARIUS (PA)
Entity type:Individual
Prefix:
First Name:BRUNO
Middle Name:MARIUS
Last Name:SUDITU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3852
Mailing Address - Country:US
Mailing Address - Phone:203-852-2000
Mailing Address - Fax:
Practice Address - Street 1:6010 BAY PKWY STE 902
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-6091
Practice Address - Country:US
Practice Address - Phone:718-475-1700
Practice Address - Fax:718-475-1702
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014453363A00000X
CT3520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03390269Medicaid