Provider Demographics
NPI:1013274679
Name:SUTHERLAND, TARA (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15555 HUNTINGTON VILLAGE LN APT 250
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3065
Mailing Address - Country:US
Mailing Address - Phone:702-769-7739
Mailing Address - Fax:
Practice Address - Street 1:2650 ELM AVE STE 301
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1600
Practice Address - Country:US
Practice Address - Phone:562-728-5034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130305208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics