Basic Information
| Provider Information | |||||||||
| NPI: | 1285797191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUKAL | ||||||||
| FirstName: | MINTRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 PONCE DE LEON BLVD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331346010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057025135 | ||||||||
| FaxNumber: | 3054412144 | ||||||||
| Practice Location | |||||||||
| Address1: | 5352 LINTON BLVD | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334846514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614984440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME98494 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NY | MEDICAID |