Basic Information
| Provider Information | |||||||||
| NPI: | 1346251089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUTHERLAND | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863407 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328863407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419172600 | ||||||||
| FaxNumber: | 9419177884 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 WALDEMERE ST STE 701 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342392913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414872160 | ||||||||
| FaxNumber: | 9414872170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME79474 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 274342600 | 05 | FL | MEDICAID | PENDING | 01 | FL | FL MEDICARE | OTHER |