Provider Demographics
NPI:1588611040
Name:SUTTON, MOIRA W (MD)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:W
Last Name:SUTTON
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:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78292-0357
Mailing Address - Country:US
Mailing Address - Phone:703-753-4045
Mailing Address - Fax:703-753-8037
Practice Address - Street 1:7901 LAKE MANASSAS DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3257
Practice Address - Country:US
Practice Address - Phone:703-753-4045
Practice Address - Fax:703-753-8037
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010122468942085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC287657Medicaid
SC287657Medicaid
SCAA13273212Medicare PIN