Provider Demographics
NPI:1821254517
Name:SUTPHIN, DANIEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:DAVID
Last Name:SUTPHIN
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 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7127
Mailing Address - Country:US
Mailing Address - Phone:928-336-1802
Mailing Address - Fax:928-336-7520
Practice Address - Street 1:2460 S PARKVIEW LOOP, SUITE 201
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-5358
Practice Address - Country:US
Practice Address - Phone:928-336-1675
Practice Address - Fax:928-336-1676
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-06162086S0122X
AZ549602086S0122X
TN451142086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77456751Medicaid
TN103I242914Medicare PIN
NM77456751Medicaid