Provider Demographics
NPI:1619281789
Name:SUTTERER, RYAN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:SUTTERER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:503 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764
Practice Address - Country:US
Practice Address - Phone:573-238-2033
Practice Address - Fax:573-238-2915
Is Sole Proprietor?:No
Enumeration Date:2010-08-01
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619281789Medicaid
MO064380022Medicare PIN