Provider Demographics
NPI:1023064706
Name:SUTHERLAND, JEROME C (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:C
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 1:10700 E GEDDES AVE
Mailing Address - Street 2:NO 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2703
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO146052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2315994Medicaid
CO01146059Medicaid
NE84-059792913Medicaid
CA1023064706Medicaid
MI104686392Medicaid
WY1023064706Medicaid
KS200425440AMedicaid
WI99112107Medicaid
TX053218601Medicaid
AZ920448Medicaid
CO300049155OtherRR RIA MCRE
CO300090380OtherRR MIC MCRE
LA2315994Medicaid
CO300090380OtherRR MIC MCRE
COCW4148Medicare PIN
MI104686392Medicaid