1528090875 NPI number — AVERELL H SUTTON M.D.

Table of content: AVERELL H SUTTON M.D. (NPI 1528090875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528090875 NPI number — AVERELL H SUTTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON
Provider First Name:
AVERELL
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528090875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 WARBLER WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAVANO PARK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78231-1431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 BROOKLYN AVE
Provider Second Line Business Practice Location Address:
220
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78212-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-228-0705
Provider Business Practice Location Address Fax Number:
210-472-0255
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  H7838 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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