Healthcare Provider Details

I. General information

NPI: 1679801609
Provider Name (Legal Business Name): CARL MASON SUTHERLAND II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 28TH AVE
SAN MATEO CA
94403-2601
US

IV. Provider business mailing address

539 28TH AVE
SAN MATEO CA
94403-2601
US

V. Phone/Fax

Practice location:
  • Phone: 650-393-4053
  • Fax:
Mailing address:
  • Phone: 650-393-4053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD.03368R
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: