Basic Information
| Provider Information | |||||||||
| NPI: | 1407896160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDUIKIS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | VERONICA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 BROOK ST | ||||||||
| Address2: | |||||||||
| City: | CARLISLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017411608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178764344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1575 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021384308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178764344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA76458 | MA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 725372 | 01 | MA | TUFTS | OTHER | 133800 | 01 | MA | HEALTHSOURCE | OTHER | J12920 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | S022064 | 01 | MA | TRICARE | OTHER | 3097501 | 05 | MA | MEDICAID | 022064 | 01 | MA | CHAMPUS | OTHER | 80137 | 01 | MA | HARVARD PILGRIM | OTHER |