Provider Demographics
NPI:1043389844
Name:SUTTON, FREDRICK
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:SUTTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BEECH BRANCH CT
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-8046
Mailing Address - Country:US
Mailing Address - Phone:803-920-7744
Mailing Address - Fax:803-407-2957
Practice Address - Street 1:15 BEECH BRANCH CT
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-8046
Practice Address - Country:US
Practice Address - Phone:803-920-7744
Practice Address - Fax:803-407-2957
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX5221Medicaid