Provider Demographics
NPI:1801879382
Name:SUTHERLAND, RANDAL M (MD)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:M
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:DEPT LA 21552
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1552
Mailing Address - Country:US
Mailing Address - Phone:949-263-8600
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:LITTLE CO MARY HOSP
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-303-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA802672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A802670OtherBLUE SHIELD
CA00A802670Medicaid
CA00A802670OtherBLUE SHIELD
G35200Medicare UPIN
CA00A802670Medicaid
CAWA80267GMedicare PIN