Provider Demographics
NPI:1487609756
Name:SUDIKOFF, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SUDIKOFF
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 1:333 CEDAR ST
Mailing Address - Street 2:PEDIATRICS/YALE UNIVERSITY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3206
Mailing Address - Country:US
Mailing Address - Phone:203-785-4651
Mailing Address - Fax:203-785-5833
Practice Address - Street 1:333 CEDAR ST
Practice Address - Street 2:PEDIATRICS/YALE UNIVERSITY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-785-4651
Practice Address - Fax:203-785-5833
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI107942080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7009818Medicaid
RI7009818Medicaid
RIG04430Medicare UPIN