Provider Demographics
NPI:1457563199
Name:SUTANTO, HEIDI B (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:B
Last Name:SUTANTO
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 1:9300 DEWITT LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5285
Mailing Address - Country:US
Mailing Address - Phone:571-231-3110
Mailing Address - Fax:571-231-6697
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:OAKS PAVILION, 1ST FLOOR
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060
Practice Address - Country:US
Practice Address - Phone:571-231-3110
Practice Address - Fax:571-231-6697
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40828208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics