Healthcare Provider Details

I. General information

NPI: 1447646872
Provider Name (Legal Business Name): NINA SUDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 KINNELON ROAD SUITE 28
KINNELON NJ
07405
US

IV. Provider business mailing address

PO BOX 95000 LB#7550
PHILADELPHIA PA
19195-7550
US

V. Phone/Fax

Practice location:
  • Phone: 973-838-1717
  • Fax: 973-838-1775
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA11106600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MA11106600
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number293447-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: