Provider Demographics
NPI:1881678183
Name:SUTULA, THOMAS LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LYNN
Last Name:SUTULA
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:714 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1035
Practice Address - Country:US
Practice Address - Phone:574-647-7477
Practice Address - Fax:574-647-3655
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036117A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000085135OtherANTHEM
IN080191116OtherRR MEDICARE
IN000000681919OtherANTHEM
IN100336100Medicaid
IN000000488324OtherANTHEM
IN000000681919OtherANTHEM
IND94685Medicare UPIN
IN100336100Medicaid
IN162520LMedicare PIN