Healthcare Provider Details

I. General information

NPI: 1871805986
Provider Name (Legal Business Name): JONATHAN BURLETT SUTTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICAL CENTER BLVD SUITE 404
CHESTER PA
19013-3955
US

IV. Provider business mailing address

30 MEDICAL CENTER BLVD SUITE 404
CHESTER PA
19013-3955
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-8590
  • Fax: 610-619-8591
Mailing address:
  • Phone: 610-497-7407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT013829
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS016858
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: