Provider Demographics
NPI:1790989663
Name:SUTHERLAND, WILLIAM RYAN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RYAN
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:227 FALCON DR STE 104
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9792
Practice Address - Country:US
Practice Address - Phone:859-497-5160
Practice Address - Fax:859-497-5166
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43004208600000X
IN01063074A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200869500AMedicaid
KY7100089710Medicaid
IN200869500TMedicaid
0816010001OtherDMERC
P00642704OtherRAILROAD MEDICARE
000000526049OtherANTHEM
IN200869500TMedicaid
IN200869500AMedicaid