Healthcare Provider Details

I. General information

NPI: 1578646477
Provider Name (Legal Business Name): SUSANA DUGANG BUNDOC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 BEACH CHANNEL DR
ARVERNE NY
11692-1409
US

IV. Provider business mailing address

741 TURF RD
VALLEY STREAM NY
11581-3505
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax:
Mailing address:
  • Phone: 516-295-6786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number213517
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: