Provider Demographics
NPI:1043885932
Name:SUDOL, IDA C (MA)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:C
Last Name:SUDOL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:C
Other - Last Name:RODRIGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:37 LOOMIS DR APT B1
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2029
Mailing Address - Country:US
Mailing Address - Phone:860-303-6157
Mailing Address - Fax:
Practice Address - Street 1:1695 MAIN ST FL 400
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1063
Practice Address - Country:US
Practice Address - Phone:431-739-5572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program