Provider Demographics
NPI:1871525279
Name:SUEDE, MOHAMAD MAHER (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:MAHER
Last Name:SUEDE
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 1:272 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3536
Mailing Address - Country:US
Mailing Address - Phone:860-432-2100
Mailing Address - Fax:860-432-5330
Practice Address - Street 1:272 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3536
Practice Address - Country:US
Practice Address - Phone:860-432-2100
Practice Address - Fax:860-432-5330
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036834208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V6079OtherOXFORD
CT036834OtherCONNECTICARE
CT00136834000Medicaid
CT010036834CT01OtherANTHEM BLUE CROSS/BLUE SH
CT020001635Medicare ID - Type Unspecified
CT00136834000Medicaid