Provider Demographics
NPI:1730164146
Name:SUTHERLAND, JEAN A (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 HARRODSBURG RD
Mailing Address - Street 2:SUITE D-502
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3758
Mailing Address - Country:US
Mailing Address - Phone:859-277-8560
Mailing Address - Fax:859-277-8866
Practice Address - Street 1:1451 HARRODSBURG RD
Practice Address - Street 2:SUITE D-502
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3758
Practice Address - Country:US
Practice Address - Phone:859-277-8560
Practice Address - Fax:859-277-8866
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64253370Medicaid
KY000000110942OtherANTHEM
KYC78343Medicare UPIN
KY64253370Medicaid