MEDICARE: DR. DAVID B SUDDERTH M.D.

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	2084N0400X	Neurology Physician	ME55197	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1902805856	OTHER	FL	NPI
2	08754	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1902805856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID B SUDDERTH M.D.

Provider Business Mailing Address
First Line	:	3210 CLEVELAND AVE
Second Line	:	SUITE 100
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7182
Country	:	US
Telephone Number	:	239-936-6778
Fax Number	:	239-210-0225

Provider Business Practice Location Address
First Line	:	3210 CLEVELAND AVE
Second Line	:	SUITE 100
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7182
Country	:	US
Telephone Number	:	239-936-6778
Fax Number	:	239-210-0225

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	06/18/2013

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