Provider Demographics
NPI:1821076464
Name:SUTLY, JOSEPH C
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:C
Last Name:SUTLY
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 1:1980 N ATLANTIC AVE
Mailing Address - Street 2:SUITE 421
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5213
Mailing Address - Country:US
Mailing Address - Phone:321-783-0130
Mailing Address - Fax:321-783-0130
Practice Address - Street 1:1980 N ATLANTIC AVE
Practice Address - Street 2:SUITE 421
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5213
Practice Address - Country:US
Practice Address - Phone:321-783-0130
Practice Address - Fax:321-783-0130
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18572208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05282Medicare ID - Type Unspecified
FLD51218Medicare UPIN