Provider Demographics
NPI:1326123100
Name:SUTHAR, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:
Last Name:SUTHAR
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 1:13710 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2602
Mailing Address - Country:US
Mailing Address - Phone:314-469-7246
Mailing Address - Fax:314-469-7251
Practice Address - Street 1:13710 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2602
Practice Address - Country:US
Practice Address - Phone:314-469-7246
Practice Address - Fax:314-469-7251
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103749208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00010977OtherRAILROAD MEDICARE
MO000013895Medicare PIN
MOP00010977OtherRAILROAD MEDICARE