Healthcare Provider Details

I. General information

NPI: 1558723288
Provider Name (Legal Business Name): EDMUND DEFOREST SUGZDINIS JR. BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 S ROCKFIELD DR
WILMINGTON DE
19810-3228
US

IV. Provider business mailing address

3407 S ROCKFIELD DR
WILMINGTON DE
19810-3228
US

V. Phone/Fax

Practice location:
  • Phone: 302-229-5216
  • Fax:
Mailing address:
  • Phone: 302-229-5216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number03-202
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberF03241
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: