Provider Demographics
NPI:1700835220
Name:SUTHERLAND, JESSE O (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:O
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 1:2200 S FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-5444
Mailing Address - Country:US
Mailing Address - Phone:303-934-4862
Mailing Address - Fax:303-937-7160
Practice Address - Street 1:2200 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-5444
Practice Address - Country:US
Practice Address - Phone:303-934-4862
Practice Address - Fax:303-937-7160
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01225630Medicaid
COC88341Medicare PIN
D24128Medicare UPIN