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General NPI Number Information
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NPI Number | 1457563199
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Entity Type | Individual
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Provider Name | HEIDI B SUTANTO M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 01/30/2019
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Provider Practice Location Address
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Address Line | 9300 DEWITT LOOP OAKS PAVILION, 1ST FLOOR
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City | FORT BELVOIR
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State | VA
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Zip | 22060
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Country | US
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Telephone | 571-231-3110
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Fax | 571-231-6697
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Provider Business Mailing Address
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Address Line | 9300 DEWITT LOOP
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City | FORT BELVOIR
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State | VA
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Zip | 22060-5285
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Country | US
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Telephone | 571-231-3110
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Fax | 571-231-6697
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 40828
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 40828
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License Number State | AZ
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