Provider Demographics
NPI:1578554606
Name:SUTHERLAND, MARK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
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:PO BOX 3686
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-0686
Mailing Address - Country:US
Mailing Address - Phone:910-442-1100
Mailing Address - Fax:910-442-1199
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-442-1100
Practice Address - Fax:910-442-1199
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00273207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2054049COtherMEDICARE PTAN
NC2054049OtherMEDICARE ID
NC5903826Medicaid
NC2054049EOtherMEDICARE PTAN
NCP00843366OtherMEDICARE RAILROAD
NC2054049COtherMEDICARE PTAN
NC1992708747Medicare PIN