Provider Demographics
NPI:1053504506
Name:SUTHAN, NANTHINI (MD)
Entity Type:Individual
Prefix:DR
First Name:NANTHINI
Middle Name:
Last Name:SUTHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TERMINAL DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2201
Mailing Address - Country:US
Mailing Address - Phone:618-258-0485
Mailing Address - Fax:618-258-4815
Practice Address - Street 1:2 TERMINAL DR
Practice Address - Street 2:SUITE 8
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2201
Practice Address - Country:US
Practice Address - Phone:618-258-0485
Practice Address - Fax:618-258-4815
Is Sole Proprietor?:No
Enumeration Date:2007-08-18
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059772207R00000X
IL036126643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA448758879AOtherPEACHCARE FOR KIDS
GA11SCHWDMedicare PIN