MEDICARE: KIM SUDAMA

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	225XP0200X	Pediatric Occupational Therapist	012854	NY

General Provider Information

NPI Number	:	1700929601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM SUDAMA

Provider Business Mailing Address
First Line	:	133 GRASSY POND DR
Second Line	:
City	:	SMITHTOWN
State	:	NY
Zip	:	11787-4273
Country	:	US
Telephone Number	:	516-906-8957
Fax Number	:

Provider Business Practice Location Address
First Line	:	1428 5TH AVE
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-4147
Country	:	US
Telephone Number	:	631-392-0081
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	11/02/2023

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Directions to “ KIM SUDAMA ” Practice Location

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