Provider Demographics
NPI:1487626750
Name:SUNDERLAND, BRENT ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ANTHONY
Last Name:SUNDERLAND
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-210-5061
Mailing Address - Fax:704-210-5337
Practice Address - Street 1:612 MOCKSVILLE AVENUE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28144-2732
Practice Address - Country:US
Practice Address - Phone:704-210-5061
Practice Address - Fax:704-210-5337
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002016312084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133CAMedicaid
SCN01632Medicaid
NC2040657Medicare PIN
NC89133CAMedicaid