Healthcare Provider Details

I. General information

NPI: 1013274679
Provider Name (Legal Business Name): TARA SUTHERLAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 ELM AVE STE 301
LONG BEACH CA
90806-1600
US

IV. Provider business mailing address

15555 HUNTINGTON VILLAGE LN APT 250
HUNTINGTON BEACH CA
92647-3065
US

V. Phone/Fax

Practice location:
  • Phone: 562-728-5034
  • Fax:
Mailing address:
  • Phone: 702-769-7739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number130305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: