Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | ME93606 | FL |
NPI | 1033162581 |
---|---|
Provider Name | Dr. Brandon K Suedekum |
First Address | Phoenix, AZ 85032-2122 |
Second Address | Phoenix, AZ 85032-2122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2006 |
Last Update Date | 13/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
111212 | MEDICARE ID (01) | AZ |
35451 | AZ MEDICAL STATE LICENSE (01) | AZ |