Healthcare Provider Details

I. General information

NPI: 1770565970
Provider Name (Legal Business Name): NEAL K SUTHERS MD DBA HUDSON-SUTHERS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HWY 64 N
BUFFALO OK
73834-0010
US

IV. Provider business mailing address

PO BOX 10
BUFFALO OK
73834-0010
US

V. Phone/Fax

Practice location:
  • Phone: 580-735-2506
  • Fax: 580-735-2728
Mailing address:
  • Phone: 580-735-2506
  • Fax: 580-735-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9573
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number9573
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number1207
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1207
License Number StateOK

VIII. Authorized Official

Name: NEAL K SUTHERS
Title or Position: OWNER
Credential: MD
Phone: 580-735-2506