Healthcare Provider Details

I. General information

NPI: 1861483414
Provider Name (Legal Business Name): DAVID M SUHOCKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 WOLCOTT RD
WOLCOTT CT
06716-2626
US

IV. Provider business mailing address

464 WOLCOTT RD
WOLCOTT CT
06716-2626
US

V. Phone/Fax

Practice location:
  • Phone: 203-879-6171
  • Fax: 203-879-1191
Mailing address:
  • Phone: 203-879-6171
  • Fax: 203-879-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001103
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: