Healthcare Provider Details

I. General information

NPI: 1275774937
Provider Name (Legal Business Name): DOMINICK GEORGE SUDANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 N CAMPBELL AVE RM 6336
TUCSON AZ
85724-0001
US

IV. Provider business mailing address

1501 N CAMPBELL AVE PO BOX 245093
TUCSON AZ
85724-0001
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-2761
  • Fax:
Mailing address:
  • Phone: 520-626-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number44910
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR70588
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: