Provider Demographics
NPI:1326008418
Name:SUTHERLAND, SCOTT B (O D)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:B
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-9104
Mailing Address - Country:US
Mailing Address - Phone:270-522-3263
Mailing Address - Fax:270-522-6240
Practice Address - Street 1:304 MAIN ST
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9104
Practice Address - Country:US
Practice Address - Phone:270-522-3263
Practice Address - Fax:270-522-6240
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY967DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009678Medicaid
KY9174001Medicare ID - Type Unspecified
KY0200790001Medicare NSC
KY77009678Medicaid