Provider Demographics
NPI:1891793139
Name:SUTTON, LADDEUS L (MD)
Entity Type:Individual
Prefix:
First Name:LADDEUS
Middle Name:L
Last Name:SUTTON
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 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2555 COURT DR STE 200
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2178
Practice Address - Country:US
Practice Address - Phone:704-868-3256
Practice Address - Fax:704-868-5870
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300332207RC0000X
SC24079207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00332Medicaid
NC8981049Medicaid
NC8981049Medicaid
NC2189138BMedicare PIN