Healthcare Provider Details

I. General information

NPI: 1639801434
Provider Name (Legal Business Name): COLE SUTHERLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE # 222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2553
  • Fax:
Mailing address:
  • Phone: 505-272-2553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-2023-0012
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3200
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: