Provider Demographics
NPI:1740227719
Name:SUTHERLAND, JERRY ESMOND (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ESMOND
Last Name:SUTHERLAND
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 1:372 OAK TRCE
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4576
Mailing Address - Country:US
Mailing Address - Phone:205-733-8139
Mailing Address - Fax:
Practice Address - Street 1:1400 WALL ST
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-6011
Practice Address - Country:US
Practice Address - Phone:256-737-9109
Practice Address - Fax:256-737-9110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-698-TA-152152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT87990Medicare UPIN