Provider Demographics
NPI:1023057353
Name:SUTHERLAND, MARK EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SUTHERLAND
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 1:2717 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3957
Mailing Address - Country:US
Mailing Address - Phone:903-792-3773
Mailing Address - Fax:903-792-1291
Practice Address - Street 1:2717 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3957
Practice Address - Country:US
Practice Address - Phone:903-792-3773
Practice Address - Fax:903-792-1291
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7221208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159065501Medicaid
AR125618001Medicaid
AR125618001Medicaid
TXE96929Medicare UPIN
TX159065501Medicaid