Healthcare Provider Details

I. General information

NPI: 1033413489
Provider Name (Legal Business Name): ROGER CARLISLE SUTTLE JR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 S 4TH ST
GADSDEN AL
35901-5215
US

IV. Provider business mailing address

414 S 4TH ST
GADSDEN AL
35901-5215
US

V. Phone/Fax

Practice location:
  • Phone: 256-543-9393
  • Fax: 256-546-8433
Mailing address:
  • Phone: 256-543-9393
  • Fax: 256-546-8433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberMD.3266
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: