Provider Demographics
NPI:1033112933
Name:SUTHERLAND, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:SUTHERLAND
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:PO BOX 7939
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-7939
Mailing Address - Country:US
Mailing Address - Phone:903-593-1738
Mailing Address - Fax:903-596-7852
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:STE 404
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1955
Practice Address - Country:US
Practice Address - Phone:903-593-1738
Practice Address - Fax:903-596-7852
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5579207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154168201Medicaid
TX154168201Medicaid
TXC33314Medicare UPIN