Provider Demographics
NPI:1740266501
Name:SUTHERLAND, SHANNON RENAE (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENAE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:RENAE
Other - Last Name:LUCENTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5901 MONCLOVA RD
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-872-3201
Mailing Address - Fax:419-872-3208
Practice Address - Street 1:1103 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1783
Practice Address - Country:US
Practice Address - Phone:419-872-3219
Practice Address - Fax:419-872-3208
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBL9255058207V00000X
OH34.008522207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2604793Medicaid
OHLU4166451Medicare ID - Type Unspecified
OH4166452Medicare PIN
OH2604793Medicaid