Healthcare Provider Details

I. General information

NPI: 1326279795
Provider Name (Legal Business Name): JOHN IVAN SUTTER, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CLIFTON AVE SUITE 102
CLIFTON NJ
07013-2724
US

IV. Provider business mailing address

925 CLIFTON AVE SUITE 102
CLIFTON NJ
07013-2724
US

V. Phone/Fax

Practice location:
  • Phone: 973-778-2083
  • Fax: 973-778-1584
Mailing address:
  • Phone: 973-778-2083
  • Fax: 973-778-1584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA03777100
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN IVAN SUTTER
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 973-778-2083