Healthcare Provider Details

I. General information

NPI: 1629375563
Provider Name (Legal Business Name): SU GULSUN G BERRAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE FL 5
BRONX NY
10467-2403
US

IV. Provider business mailing address

3415 BAINBRIDGE AVE FL 5
BRONX NY
10467-2403
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2450
  • Fax: 718-944-5908
Mailing address:
  • Phone: 718-741-2450
  • Fax: 718-944-5908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number268377
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: