Provider Demographics
NPI:1376643759
Name:SUTHERLAND, WILLIAM K (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:K
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 1:1020 RIVER OAK DRIVE, STE 310
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-932-5006
Mailing Address - Fax:601-932-4548
Practice Address - Street 1:1020 RIVER OAK DRIVE,
Practice Address - Street 2:STE 310
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-932-5006
Practice Address - Fax:601-932-4548
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09328207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121296Medicaid
MS00121296Medicaid
MSB29979Medicare UPIN