Healthcare Provider Details

I. General information

NPI: 1225272248
Provider Name (Legal Business Name): KATARZYNA IRENA DUDYCZ-SULICZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4417 VESTAL PKWY E
VESTAL NY
13850-3556
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2580
US

V. Phone/Fax

Practice location:
  • Phone: 607-797-1251
  • Fax: 607-729-4393
Mailing address:
  • Phone: 607-797-1251
  • Fax: 607-729-4393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42542
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number273928
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: