1720102239 NPI number — MS. DIANE STARK SUDA MSW

Table of content: MS. DIANE STARK SUDA MSW (NPI 1720102239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720102239 NPI number — MS. DIANE STARK SUDA MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUDA
Provider First Name:
DIANE
Provider Middle Name:
STARK
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STARK
Provider Other First Name:
DIANE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720102239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 SHADYSIDE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYCKOFF
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-891-5148
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 FRANKLIN TURNPIKE
Provider Second Line Business Practice Location Address:
SECOND FLOOR
Provider Business Practice Location Address City Name:
WALDWICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-612-0550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  44SC00190100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 163W00000X , with the licence number: 26NR03997100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00114374 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".