Provider Demographics
NPI:1639194764
Name:SUTHERLAND, CARISA M (MD)
Entity Type:Individual
Prefix:
First Name:CARISA
Middle Name:M
Last Name:SUTHERLAND
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 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:704-304-6400
Mailing Address - Fax:704-442-7021
Practice Address - Street 1:231 S SHARON AMITY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2803
Practice Address - Country:US
Practice Address - Phone:704-304-6400
Practice Address - Fax:704-442-7021
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-001202080A0000X, 2080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0012BMedicaid
NC1639194764Medicaid
NC5906365Medicaid
NCNC8006DMedicare PIN
SCN0012BMedicaid
NC5906365Medicaid
NC1639194764Medicaid
NCNC8006NMedicare PIN
NCNC8006AMedicare PIN