Provider Demographics
NPI:1164487534
Name:SUTTER, CONNIE D (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:D
Last Name:SUTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:D
Other - Last Name:SUTTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6701 ROCKSIDE RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2358
Mailing Address - Country:US
Mailing Address - Phone:216-524-4009
Mailing Address - Fax:216-524-7933
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:SUITE 330
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-524-4009
Practice Address - Fax:216-524-7933
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058075207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0736127Medicaid
OH000000139990OtherANTHEM
OHT58075OtherSUMMACARE
OH0632143Medicare PIN
OH000000139990OtherANTHEM
D98057Medicare UPIN