Provider Demographics
NPI:1760476295
Name:SUTHERLAND, G LEWIS
Entity Type:Individual
Prefix:
First Name:G
Middle Name:LEWIS
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2387 PROFESSIONAL HEIGHTS DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3038
Mailing Address - Country:US
Mailing Address - Phone:859-278-7011
Mailing Address - Fax:859-278-2015
Practice Address - Street 1:2387 PROFESSIOINAL HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3038
Practice Address - Country:US
Practice Address - Phone:859-278-7011
Practice Address - Fax:859-278-2015
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY117213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80001175Medicaid
KYT54192Medicare UPIN
KY0495020001Medicare NSC
KY80001175Medicaid