Provider Demographics
NPI:1174712103
Name:SULIENE, DALIA (MD)
Entity type:Individual
Prefix:
First Name:DALIA
Middle Name:
Last Name:SULIENE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9485
Mailing Address - Country:US
Mailing Address - Phone:608-742-9100
Mailing Address - Fax:
Practice Address - Street 1:2925 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9485
Practice Address - Country:US
Practice Address - Phone:608-742-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine