Basic Information
| Provider Information | |||||||||
| NPI: | 1780636423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTTERLIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303530062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436956071 | ||||||||
| FaxNumber: | 8435695879 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 S ALLIANCE DR STE 211B | ||||||||
| Address2: | |||||||||
| City: | GOOSE CREEK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294457269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435534383 | ||||||||
| FaxNumber: | 8435534384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17955 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080187342 | 01 | SC | RR MEDICARE | OTHER | 179550 | 05 | SC | MEDICAID |