Healthcare Provider Details

I. General information

NPI: 1659355626
Provider Name (Legal Business Name): CAROL A SUTTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 9TH ST
PORT ST JOE FL
32456-1924
US

IV. Provider business mailing address

PO BOX 476 21890 NE CR 69A
BLOUNTSTOWN FL
32424-0476
US

V. Phone/Fax

Practice location:
  • Phone: 850-229-8244
  • Fax: 850-229-6003
Mailing address:
  • Phone: 850-674-4422
  • Fax: 850-674-4422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME 47545
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: