Provider Demographics
NPI:1568870970
Name:SUNDERLAND, JOHN EDWIN (ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWIN
Last Name:SUNDERLAND
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 CONCORD LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-6127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:504 CONCORD LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-6127
Practice Address - Country:US
Practice Address - Phone:405-514-1215
Practice Address - Fax:405-974-3805
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK501Medicaid