Provider Demographics
NPI:1780791202
Name:DESUTTER, JOHN HENRY (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HENRY
Last Name:DESUTTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9659 E. GOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654
Mailing Address - Country:US
Mailing Address - Phone:662-895-2501
Mailing Address - Fax:662-895-3464
Practice Address - Street 1:9659 E. GOODMAN AVE
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-895-2501
Practice Address - Fax:662-895-3464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0059111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T21143Medicare UPIN