Healthcare Provider Details

I. General information

NPI: 1407848575
Provider Name (Legal Business Name): JOHN IVAN SUTTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CLIFTON AVE SUITE 102
CLIFTON NJ
07013-2724
US

IV. Provider business mailing address

11 CHITTENDEN RD STE 102
CLIFTON NJ
07013-4203
US

V. Phone/Fax

Practice location:
  • Phone: 973-778-2083
  • Fax: 973-778-1584
Mailing address:
  • Phone: 201-456-4251
  • Fax: 973-778-1584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMA037771
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA03777100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: