Provider Demographics
NPI:1831700848
Name:SUTHAR, ANIL (LMT)
Entity type:Individual
Prefix:
First Name:ANIL
Middle Name:
Last Name:SUTHAR
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11776 WATTLE TREE RD N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-9751
Mailing Address - Country:US
Mailing Address - Phone:904-955-3029
Mailing Address - Fax:
Practice Address - Street 1:11776 WATTLE TREE RD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-9751
Practice Address - Country:US
Practice Address - Phone:904-955-3029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMEBTVRHLLMedicaid
SELFOtherSELF