Provider Demographics
NPI:1184619264
Name:SUDILOVSKY, DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:SUDILOVSKY
Suffix:
Gender:M
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:PO BOX 1849
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1849
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-1439
Practice Address - Street 1:101 DATES DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-274-4474
Practice Address - Fax:607-274-4481
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237344207ZP0105X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8034Medicare PIN
NYG62524Medicare UPIN