Provider Demographics
NPI:1366331027
Name:SUMO KOUATCHO, LUC LANDRY
Entity type:Individual
Prefix:
First Name:LUC LANDRY
Middle Name:
Last Name:SUMO KOUATCHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 KISSEL AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1636
Mailing Address - Country:US
Mailing Address - Phone:240-491-1319
Mailing Address - Fax:
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1664
Practice Address - Country:US
Practice Address - Phone:718-818-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital