Provider Demographics
NPI:1619945300
Name:SUTHERLAND, CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 CORONA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2582
Mailing Address - Country:US
Mailing Address - Phone:573-234-1800
Mailing Address - Fax:
Practice Address - Street 1:2101 CORONA RD STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2582
Practice Address - Country:US
Practice Address - Phone:573-234-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245101407Medicaid
MO000094803Medicare ID - Type Unspecified
MOE96934Medicare UPIN