Provider Demographics
NPI:1528130754
Name:SUDACK, PAUL STEVEN (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:STEVEN
Last Name:SUDACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WESTWARD DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5259
Mailing Address - Country:US
Mailing Address - Phone:305-887-4494
Mailing Address - Fax:305-887-1475
Practice Address - Street 1:215 WESTWARD DR
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-5259
Practice Address - Country:US
Practice Address - Phone:305-887-4494
Practice Address - Fax:305-887-1475
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL41103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D27936Medicare UPIN