MEDICARE: SUDARA PT PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	030017-1	NY

General Provider Information

NPI Number	:	1043517790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUDARA PT PC

Provider Business Mailing Address
First Line	:	5327 18TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1523
Country	:	US
Telephone Number	:	718-236-7707
Fax Number	:	718-236-3300

Provider Business Practice Location Address
First Line	:	5327 18TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1523
Country	:	US
Telephone Number	:	718-236-7707
Fax Number	:	718-236-3300

Authorized Official
Title or Position	:	P.T.
Name	:	DAVID PEREZ- HERRANZ
Credential	:	P.T.
Telephone Number	:	718-236-7707

Provider Enumeration Date	:	02/15/2011
Last Update Date	:	02/15/2011

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