Provider Demographics
NPI:1366215410
Name:SUGARMAN, MIA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:SUGARMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1304
Mailing Address - Country:US
Mailing Address - Phone:857-544-5309
Mailing Address - Fax:
Practice Address - Street 1:245 E 63RD ST APT 1111
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7457
Practice Address - Country:US
Practice Address - Phone:857-544-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
366215410OtherBELLY