Provider Demographics
NPI:1477568954
Name:SUTPHEN, REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SUTPHEN
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 1:111 2ND AVE NE STE 700
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3441
Mailing Address - Country:US
Mailing Address - Phone:800-975-4819
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 700
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3441
Practice Address - Country:US
Practice Address - Phone:800-975-4819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061423207SC0300X, 207SG0203X, 207SG0201X
FLME61423208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31447OtherBLUE CROSS BLUE SHIELD
FL250378600Medicaid
FL31447YMedicare ID - Type Unspecified
FL250378600Medicaid
FL31447XMedicare PIN